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DocuSign Envelope ID:OE8OF166-E23E-463F-BEEB-F904441OC416 <br /> ��Q�Ytea« SAW WORKERS COMPENSATION <br /> lL AND <br /> ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br /> HARTFORD CT 06183 <br /> ENDORSEMENT WC 99 03 76 ( A) - 001 <br /> POLICY NUMBER: UB6K989215 <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 organization named in the Schedule. <br /> The additional premium for this endorsement shall be 2.00 % of the California workers' compensation pre- <br /> mium. <br /> Schedule <br /> Person or Organization Job Description <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 /> INCLUDING: <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 <br /> Insurance Company Countersigned by <br /> ST ASSIGN: Page 1 of 1 <br />