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DocuSign Envelope ID: BDDDD430-E4C8-4429-B240-4E14BF7C5CC7 <br /> jjJ i[L�t LEI f- [1-,�� ��J eD WORKERS COMPENSATION <br /> AND <br /> HIDE TOWER SQUARE HARTFORD CT 06183 EMPLOYERS LIABILITY POLICY <br /> ENDORSEMENT VVC 00 03 13 (01)) - 001 <br /> POLICYNUMBER: UH—OIC464798-19-42—G <br /> WAQVE R OF OUR R GHTT O RECOVER FROM OTHERS ENDORSE-fi11ENT <br /> We have the right to recover Our payments from anyone liable for an injury covered by this policy. We will not <br /> enforce our right against the person or organization named in the Schedule. {This agreement applies only to the <br /> extent that you 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 any one not named in the Schedule. <br /> SCHEDULE <br /> DESIGNATED PERSON: <br /> DESIGNATED ORGANIZATION: <br /> ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED <br /> BY WRITTEN CONTRACT EXECUTED PRIOR TO TOSS TO FURNISH THIS <br /> WAIVER. <br /> 0 <br /> C <br /> QS <br /> O� <br /> O® <br /> O <br /> n <br /> N <br /> W� <br /> O <br /> 0 <br /> 0 <br /> 009440 DATE OF ISSUE: 12-21-18 STASSIGN: PAGE 1 OF <br />