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WORKERS COMPENSATION <br /> TRAVELERSr AND <br /> ONE TUBER SQUARE EMPLOYERS LIABILITY POLICY <br /> HARTFORDt CT 06183 <br /> ENDORSEMENT WC 99 03 79 ( A)- 001 <br /> POLICY NUMBER: (HOUB-7615X00-3-14) <br /> WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br /> ENDORSEMENT - CALIFORNIA <br /> j (BLANKET WAIVER) <br /> i <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 07.000 % of the California workers' compensation pre- <br /> mium. <br /> Schedule <br /> Person or Organization Job Description <br /> ANY PERSON OR ORGANIZATION <br /> FOR WHICH THE INSURED HAS <br /> AGREED BY WRITTEN CONTRACT <br /> EXECUTED PRIOR TO LOSS TO <br /> FURNISK THIS WAIVER. <br /> AME <br /> I <br /> m� <br /> MERE <br /> IT=— <br /> Its <br /> oil <br /> �me-= This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise <br /> 0=_—_ 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 /> DATE OF ISSUE: 03-07-14 ST ASSIGN: Page 1 of 1 <br /> OM78 <br />