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TRAVELERSJ <br />ONE TOWER SQUARE <br />HARTFORD CT 06183 <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76 ( A) <br />POLICY NUMBER; UB-SJ034006 <br />IYAIVER OF OUR RIGHT TO RECOVER <br />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 organization named in the Schedule. <br />The additional premium for this endorsement shall be 3.00 <br />mium. <br />Schedule <br />Person or Organization <br />ANY PERSON OR ORGANIZATION FOR <br />WHICH THE INSURED HAS AGREED <br />BY WRITTEN CONTRACT EXECUTED <br />PRIOR TO LOSS TO FURNISH THIS <br />WAIVER. <br />% of the California workers` compensation pre - <br />.lob Description <br />ENGINEERS PLAN <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise <br />stated, <br />(The information below is required only when this endorsement is issued subsequent to preparation of <br />the policy.) <br />Endorsement Effective Policy No. Endorsement No. <br />Insured Premium. tk <br />AY' <br />Insurance Company Countersigned by J(� <br />" . <br />DATE OF ISSUE: ST ASSIGN: Fuge 1 of 1 <br />