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WORKERS COMPENSATION <br />(BLANKET WAIVER) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />POLICY NUMBER: <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT – CALIFORNIA <br />ENDORSEMENT WC 99 03 76 ( A) - <br />UB-9L19981A-22-43-G <br />HARTFORD CT 06183 <br />ONE TOWER SQUARE <br />001 <br />Schedule <br />Job DescriptionPerson or Organization <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 />2.00 <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 />Countersigned byInsurance Company <br />PremiumInsured <br />Endorsement No.Policy No.Endorsement Effective <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 />ST ASSIGN: DATE OF ISSUE: Page of05-23-22 1 1 <br />Docusign Envelope ID: 4D8D057E-4488-45E9-BA32-D570041D40D0