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DocuSign Envelope ID: 08748A51- lEAE -4B4E- 8838- 31BB89500F78 <br />WORKERS COMPENSATION AND EMPLOYERS L IAWLITY €NSURA14CE POt.tt:Y WC 0a 03 1131 <br />_ ................. .. ......... ........ .... ........... .....w:. (Ed. 4- &4`1 <br />WANER OF OUR PIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br />Ova r4ase the right try rtcover or.�r paymefit5' ;rn anyone fiabie €car an injury covered by ifri; paii€y. Wo w-T not enforce <br />our right against the perm or orgar zzAbn named in the Sc tedule. ►;This ac memen` applies only to the extent thaL <br />you parf6rm 3vork under a wrote n wr�Lract that rtquiTes you, to ol~tain €tai$ agreement from us.) <br />This agreem ?ent shatl not operate di, ectiy Of irndirec€1y to bene i anyone not narned jr, 'he Schedule. <br />Schedule <br />Blanket Waiver <br />1� �'x4i't (i�l' T3rri;r3Y3CPr3: 61anket Waiver - Any pw5ion Dr fr;3ani%;i1inji ftir SsiFC +3"i ti -te t4amed TrFsur °f' has <br />s?dr ittet -, contrast rN furnish this S.l+aive'" <br />3ca a r3escrtlate¢sa� walvar Premium <br />AH RFC A .Perations 14 #.00 <br />This emJo.sl�rneni cnannas fF plicy to which it is amtohad and i9 Oective on the da #e issued un #ass 4,hanvise stated. <br />(Ti G information below is required only whim this ondorsemom it is;suad sub�sZquot t to praparaYicn Of the policy,) <br />Endorssrnsnt <br />Insured <br />lnsuranc,e Co{P p,-r,.y. <br />WC 00 03 13 <br />(Ed. x-84) <br />Q 1933 NaVomf Coons- on Cu mp�oioo 1ncurunae. <br />E`isciivr� Pc2tCtf No, PRWC836165 <br />................ <br />