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4 <br />TRAVELERSJ' k WORKERS COMPENSATION <br />AND <br />ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD CT 06183 <br />ENDORSEMENT WC 99 03 76 ( A) - 001 <br />POLICY NUMBER: UB -8K027833 -21-43-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 2 .00 % of the California workers' compensation pre- <br />mium. <br />Schedule <br />Person or Organization <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 />THE CITY OF RIVERSIDE, ITS <br />OFFICERS, EMPLOYEES AND AGENTS <br />RISK MANAGEMENT 3900 MAIN <br />STREET RIVERSIDE, CA 92522 RE: <br />FOR THE CITY OF RIVERSIDE - <br />MISCELLANEOUS ON-CALL <br />ENVIRONMENTAL TESTING <br />SERVICES. <br />Job Description <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 05/01/21 Policy No. UB -8K027833 -21-43-G Endorsement No. <br />Insured BSK Associates Premium <br />DATE OF ISSUE: 05-01-21 ST ASSIGN: Page 1 of 1 <br />004469 <br />