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DocuSign Envelope ID: 11591086 - 0989- 4E2D- 8A03- 5E4CDBBE1178 <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 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 11/4/2014 Policy No. 5H2O546 Endorsement No. 1 <br />Insured TILE RESTORATION, INC. Premium $ <br />Insurance Company EMASCO INSURANCE COMPANY Countersigned by &404 -; U t-4�� <br />WC 00 03 13 <br />(Ed. 4 -84) Copyright 1983 National Council on Compensation Insurance. <br />