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DocuSign Envelope ID: 4BE41 ABD-CDC3-4DEF-91 DE -1 EFE877592DC <br />TRAVELERST <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 9103 76 ( A) — <br />POLICY NUMBER: UB2X4374752326G <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 % of the California workers' compensation pre- <br />mium. <br />Schedule <br />Person or Organization Job Description <br />Any person or organization for whom the All California Operations. <br />Named Insured has agreed by written contract <br />to furnish this waiver. <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 10/1/2023 Policy No. UB2X4374752326G Endorsement No. <br />Insured: Columbia Electric, Inc. Premium <br />Insurance Company Travelers Property Casualty Countersigned by <br />Company of America <br />DATE OF ISSUE: 10/1/2023 ST ASSIGN: Page 1 of 1 <br />