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DocuSign Envelope ID:569754E1-D2B6-4DBE-B14F-1579C72E692B <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 /> 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 /> Liberty Insurance Corporation 21814 <br /> WA7-62D-094060-013 <br />