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WC 00 03 13 © 1983 National Council on Compensation Insurance, Inc. Page 1 of 1 Ed. 4/1/1984 WAIVER OF OUR RIGHT TO RECO VE R FROM O THERS ENDORSEMENT 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 />Issued by: <br />For attachment to Policy No Effective Date Premium $ WA7-62D-094060-013 <br />Any person or organization for which the employer has agreed by written contract, executed prior to loss, may <br />execute a waiver of subrogation. However, for purposes of work performed by the employer in Missouri, this waiver <br />of subrogation does not apply to any construction group of classifications as designated by the waiver of right to <br />recover from others (subrogation) rule in our manual. <br />Where required by contract or written agreement prior to loss and <br />allowed by law. <br />In the state of Connecticut, Florida, Maryland, Nebraska, Oregon the <br />premium charge is 1 % of the total manual premium, subject to a minimum <br />premium of $250 per policy. <br />In the state of Hawaii, the premium charge is $250 and determined as <br />follows: The premium charge for this endorsement is 1 % of the total <br />manual premium, subject to a minimum premium of $250 per policy. <br />In the state of Louisiana, the premium charge is 2% of the total standard <br />premium, subject to a minimum premium of $250 per policy. <br />In the state of Massachusetts, the premium charge is 1 % of the total <br />manual premium. <br />In the state of New York, the premium charge is 2% of the total manual <br />premium, subject to a minimum premium of $0 per policy. <br />In the state of North Carolina, the premium charge is 2% of the total <br />manual premium, subject to a minimum premium of $100 per policy. <br />In the state of Virginia, the premium charge is 5% of the total manual <br />premium, subject to a minimum premium of $250 per policy. <br />Not applicable in Kentucky, New Hampshire and New Jersey. <br />This waiver does not apply to any right to recover payments which the <br />Minnesota Workers Compensation Reinsurance Association may have or pursue <br />under M.S. 79.36 <br />Liberty Insurance Corporation 21814 DocuSign Envelope ID: 569754E1-D2B6-4DBE-B14F-1579C72E692B