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WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY ONE TOWER SQUARE HARTFORD CT 06183 <br />DATE OF ISSUE: ST ASSIGN: Page 1 of 1 12-26-25 <br />ENDORSEMENT WC 99 03 76 ( A) - 001 <br />POLICY NUMBER: UB-A7411942-26-47-G <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 <br />mium. <br />2.00 % of the California workers' compensation pre- <br />Person or Organization <br />Schedule <br />Job Description <br />ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER. INCLUDING: ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER. <br />ENGINEERING SERVICES <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 <br />Insured <br />Policy No. Endorsement No. <br />Premium <br />Docusign Envelope ID: 471CA0CF-5953-892C-80C6-A271E430039E