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WC 00 03 13 (04 84) <br />Copyright 1983, National Council on Compensation Insurance, Inc. <br />Page 1 of 1 <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 00 03 13 (Ed. 04 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 <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 anyone not named in the Schedule. <br />Schedule <br />“Organizations for which the Named Insured has agreed to by written contract executed prior to the loss to furnish waiver” <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 No. <br />Premium $ <br />Endorsement Effective 1/6/2021 Policy No. A823975 <br />Insured ASJ Wilson Construction, LLC <br />Insurance Company West Bend Mutual Insurance Countersigned by ____________________________________________ <br />DocuSign Envelope ID: D615130F-0EE1-4BD5-9ACB-9D82FFE3502C