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DocuSign Envelope ID: 313DA256 -1 EDE- 4396- A716- 4C53B809027E <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 <br />(Ed. 4 -84) <br />a <br />W <br />n <br />N <br />0 <br />rn <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 ORGA1h]TZATION WHEN REQUIRED BY WRITTEN CCNTRACT <br />This endorsement changes the policy 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 09/18/2017 Policy No. WCP 1053448 Endorsement No, OC4 <br />Insured H.M. KERN CORPORA'T'ION <br />Insurance Company BJILDERS MUTUAL INSURANCE CO Countersigned by <br />WC 40 03 13 <br />(Ed. 4 -84) Copyright 1983 National Council on Compensation Insurance. <br />