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DocuSign Envelope ID: B4147DBA-A745-4301-8830-4D6AA065FFFF <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 not enforce <br /> our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you <br /> perform work under a written contract that requires you to obtain this agreement from us.) <br /> This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. <br /> Schedule <br /> ALL PERSONS AND/OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN <br /> CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE <br /> ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS <br /> POLICY FOR WORK PERFORMED BY YOU FOR THAT PERSON AND/OR ORGANIZATION <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 04/01/2019 Policy No. WC 8343871-23 Endorsement No. <br /> Insured Premium$ <br /> Insurance Company C r r r Countersigned By <br /> WC 00 03 13 <br /> (Ed. 4-84) <br /> Copyright 1983 National Council on Compensation Insurance <br />