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DocuSign Envelope ID: 7A1847E6 -6A67- 4915 - 9630 -D7El l2028605 <br />WORKERS COMPENSATION AND EMPLOYERS €. €AWL TY INSUPA14CE POLICY WC 00 03 is <br />_...._ ................. ......... ............................w:. (d. 4-84) <br />WAWER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMeNT <br />4'Va rave the right to recover oer paymerlt• fianl a€iyone liable for an injury covewl by £krik prDc;. We w-:-11 FIDt enforce <br />our right aclairst the person or orgzinj ation named in the aczedule. Jbis agmo-men` ap,,)l:es oniy to tt:e extent that <br />you pariorm -work wider a rrti en contract that requi ;es you to obtain €his agreement from us.) <br />This agreem ?ent shall riot operate di> ectiy or indirectly to one ii anyone not ranted jr, 'he Sc`jedute. <br />Schedule <br />Blanket Waiver <br />Person/0 rsia nization- Blanket Waiver - Any p -arsoo Uf CsFtsaRi },'°, [iprt i"C3r tt "sC' i4enz °{l JroSL!r.: has <br />I:tv vd Etter-- !700t'ad 4S fOr &'.i9h Mis rYaive,. <br />Sala Waiver Premium <br />hfi RFC q .Peratiosis 14#.00 <br />Tt s endor5emanl c tangos the PE,'16cy to erhtK,.h it is ZFiachej and iy affective on the d? #p issued un #ass direr iue 4taiEEd. <br />(The #nformatlort below is required arFfy when this is; jwi,ted subr.,querit to prapsration of fbs ¢oTcy,) <br />Endorssmr;ni <br />insured <br />lnsurance Comp-r - -ry <br />We 00 03 13 <br />(Ed. s -84) <br />Q 1931 Naliomf cotantit cn cvmr, &*ic n 3flf6uranon. <br />�€$ciivr� Po2tCtf Nv, PRWC836165 <br />L'hunfarsig sed > }...r i,J.J ----- ----- ..._............. <br />I <br />