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DocuSign Envelope ID: E67DC299-98E1-4682-B281-3085AC9FC5B4 <br /> DNA Workers Compensation And Employers Liability Insurance <br /> Policy Endorsement <br /> ��OTHERS ENDORSEMENT <br /> This endorsement applies only to the insurance provided by the policy because Texas is shown in Item 3.A. of <br /> the Information Page. <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, but this waiver applies only with <br /> respect to bodily injury arising out of the operations described in the Schedule where you are required by a <br /> written contract to obtain this waiver from us. <br /> This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. <br /> The premium for this endorsement is shown in the Schedule. <br /> Schedule <br /> 1. Specific Waiver <br /> Name of person or organization <br /> X❑ Blanket Waiver <br /> Any person or organization for whom the Named Insured has agreed by written contract to furnish this <br /> waiver. <br /> 2. Operations: All Texas Operations <br /> 3. Premium: <br /> The premium charge for this endorsement shall be 2% percent of the premium developed on payroll in <br /> connection with work performed for the above person(s) or organization(s) arising out of the operations <br /> described. <br /> 4. Advance Premium: Refer to Schedule of Operations <br /> All other terms and conditions of the policy remain unchanged. <br /> This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, <br /> takes effect on the Policy Effective Date of said policy at the hour stated in said policy, unless another <br /> effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy <br /> unless another expiration date is shown below. <br /> Form No: WC 42 03 04 B (06-2014) Policy No:6079684599 <br /> Endorsement Effective Date: 11/15/2021 Endorsement Expiration Date: 11/15/2022 Policy Effective Date: 11/15/2021 <br /> Endorsement No: 56; Page: 1 of 1 Policy Page: 213 of 219 <br /> Underwriting Company: The Continental Insurance Company, 151 N Franklin St, Chicago, IL 60606 <br /> Copyright 2014 National Council on Compensation Insurance, Inc. All Rights Reserved. <br />