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DocuSign Envelope ID:622E9DC1-81`03-4131 C-AA8A-1 1 C1 D46D7FEA <br /> WORKERS COMPENSAIION AND EMPLOYERS LfABILITY INSURANCE POLICY We 00 03 13 <br /> (Ed,4-C 4) <br /> WAN ER OP OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br /> Wo havt than right lo mr*vor our paymerft from aayone lVable:fads`an Injury WvOrOKI by thi$00t '-W-)milli i"t enforca <br /> our rW(Nal,,jst ilia p9m)n or oiganl7wtion iiamaJ in tt* Sctiedule, (Tt'dS agreemenI 8PI)RCIS,OMY It)the 0440t RIM <br /> you pqrforM,woik jotwior as ver3tan wntract 1twit requiras you to obun Oft agreemenit flom us) <br /> Thiv agreemarti Shall not cp,-Kate directly or irdrectly to ba;*fil anyone rx)t samed In the ScheWta <br /> scwule <br /> glankea Wafver -Any portion or orgaNy.a0un for wtom tbr Named Insureo has <br /> jgrfPd by writren mimact to rumish tints waavef, <br /> Job Description <br /> All NC Operations <br /> TWi endort;mrool Owips(he P lov to wtije4l it jN orjut;had ethd it oft#ctivo m the date isaved unlerm OtN"Wiml shtWid. <br /> (The Informimtkio hat ow iv required only when this 011docawma"t Is isauod skubx*quoint to prepar"flan Q4 QW pollcy.) <br /> Endomorniont Efftmfivo Paat¢cy No. No, <br /> lAsurse <br /> Insurance C.'ompai,.y (:ovntamigrmd by (05-1)' �* ' <br /> Wo 00 03 13 <br /> ¢1.4-84) <br /> 1"3 1fQV*nQ1 coweA on comr*mowl <br />