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DocuSign Envelope ID: D7E43DD4-EA19-459A-861F-E601909C0459 <br /> WORKERS COMPENSAMON AND EMPLOYERS LfA'SIL"INSURANCE POLICY WC 00 03 Is <br /> WANtR Or-OUR RKIsHT TO RECOWR FROM OTHERS ENDORSEMENT <br /> We have than fight 10 revvw out pay(narrts.from a,,jyune Jklbie jot an Injunj coveted by thi$000CY.WS Will ky-A 4500m,'% <br /> our rW cgajtjst flay parson tv uiganization mmed in'tie Schedule, ffh6 agmement apphas MY to the extent 9uA <br /> you tWrorm,wofk wKsar a wriftw)Contract that requ4es you to obtain this agreemend 11m 00.) <br /> This sgra(mwrij shall not*perate&eMy or irdrectly to bm*fit anyone not narned in tho S'Cuduk: <br /> sch,604, <br /> Blanket Waiver <br /> ftruaft/orgonixotiom slanket waiver-.Any person or orgimly.ution for wtv>M the Name6 IFISLIred hag, <br /> mgrped by writTpn coin tract to turnish mis waiver. <br /> 30h Description <br /> All 14C oprraiimi <br /> Tt endorwmwmil,Lhango*the 9060)p ter' it ft liti situchad antl is"ective Cm the data!i3dued Urdass oth4nWiou Sloted. <br /> (The Informattan below 10 t*qvlrgd 0111V When thig Is j%suod subse4imfit to preparnEim of the PQRCYJ <br /> ErKlomernant Efluotive POL-y No -'a <br /> Insured <br /> tnsurarice Company <br /> WC 00 03 13 <br /> (Ed,il,-94) <br /> M3 XhIp.mv, <br />