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TRAVELERS' <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC SD03Ta( A) — <br />POLICY NUMBER: ' UB-7B37616-7.17 <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />ENDORSEMENT- CALIFORNIA <br />(BLANKET WAIVER) <br />We have the right to recover our payments from anyone liable for an Injury covered by this policy. We will not <br />enforce our right against the person or organh allon named In the Schedule. <br />The additional premium for thla endorsement shall be % of the California workers' compensation pre. <br />mium. <br />Schedule <br />Person or Organization Job Description <br />Any person or orgsnizatiea for whichthe insured has agreed by written contract <br />executed prior to Loss to furnish this waiver, <br />This endorsement changes the policy to which it la st echad and le effective on the dale Issued unless otherwise <br />staled. <br />(The Infonnallon below Is required only when this endorsement Is Issued subsequent to preparation of <br />the polloy.) <br />Endorsement Effective 07/01/17 POlIcyNM UB-7E37616-7-17 Endorsement No. <br />Insured Elaaewa i a Premium <br />Insurance Company Countersigned by <br />Travelare Property Casualty of America <br />DATE OF ISSUE: - • ST ASSIGN: page 1 of 1 <br />