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DocuSign Envelope ID:61 D935B5-E8CF-4CEE-BB06-4E876E1 11 5DO <br /> WORKERS COMPENSAMON AND EMPLOYERS LIABILITY WSURANCE POLICY WC 00#31g <br /> (Ed.4-84) <br /> WArVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br /> 4 will to a Ifore'- <br /> We have lthaVht to reww out paymards tMin anyme liable for an lQjWj WVeMd bY thiS 130licV.Wt f <br /> our Vt against Me Pam.n or mganizatk""named in the Schedule.(This agreement applies Only to the Wtent th8l <br /> you pmrbrm,vmfk joider a writer COMI-met trier requires y0l)10 Obtain this agreemOrt iMM us.) <br /> This agrament shall not ate crffeMy or indllrec(€V to bOMS1 911y0ne not narred in the Sc hsdtdO <br /> Schedule <br /> Blanket Waiver <br /> Blanket Waiver-Any person or orgaNyabon for w1v>m the Namead Insured has <br /> agreed by written mitract to furmsh this waiver. <br /> 30b Description <br /> All NC Operations <br /> This endomement charips[he paw to wtkh�is ailmhad and is eflective an the date issued urdeas ot>mmldoa$taw, <br /> (The InformtIon below is required mly when this andorammist Is lasuAd sues ate 10 PraPAtation Of em PO4Y.) <br /> Endomemant Effective P011GY No, X78 EFW-'--ptm�No. <br /> EPPSUrec 0;z T <br /> 'ex <br /> Insurame C*mpmny CowAsrsigimd by. <br /> WC 00 03 13 <br /> (Ed.4-84) <br /> 01943 Nothm,c4mroffl 6 n compommisl6n <br />