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DocuSign Envelope ID: D0190336-4C5C-477F-8902-D25F819470B6 <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 <br /> (Ed. 4-84) <br /> WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br /> We have the right to recover our payments from anyone liable for an injury covered by this policy, We will' <br /> not enforce our right against the person or organization named in the Schedule. (This agreement applies <br /> only to the extent that you perform work under a written contract that requires you to obtain this <br /> agreement from us.) <br /> This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. <br /> Schedule <br /> Any person or organization that you perform work for that is liable for an injury, covered by this policy, that <br /> prior to the injury has written contract requiring a waiver of our right to recover from them. <br /> NORTH CAROLINA <br /> This endorsement changes the poflcy to which It Is attached and is effective on the date Issued unless otherwise stated. <br /> (The information below is required only when this endorsement Is Issued subsequent to preparation of the policy) <br /> Endorsement Effective 11/4/2014 Policy No. 5H20546 Endorsement No. <br /> Insured TILE RESTORATION, INC. Premium$ <br /> Insurance Company EMASCO INSURANCE COMPANY Countersigned by <br /> WC 00 03 13 <br /> (Ed. 4-84) Copyright 1983 National Council on Compensation Insurance, <br />