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WC 00 03 13 © 1983 National Council on Compensation Insurance, Inc. Page 1 of 1 <br />Ed. 4/1/1984 <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 />Issued by: <br />For attachment to Policy No Effective Date Premium $ <br />Issued to: <br />:$' <br />$Q\SHUVRQRURUJDQL]DWLRQIRUZKLFKWKHHPSOR\HUKDVDJUHHGE\ZULWWHQFRQWUDFWH[HFXWHGSULRUWRORVVPD\ <br />H[HFXWHDZDLYHURIVXEURJDWLRQ+RZHYHUIRUSXUSRVHVRIZRUNSHUIRUPHGE\WKHHPSOR\HULQ0LVVRXULWKLVZDLYHU <br />RIVXEURJDWLRQGRHVQRWDSSO\WRDQ\FRQVWUXFWLRQJURXSRIFODVVLILFDWLRQVDVGHVLJQDWHGE\WKHZDLYHURIULJKWWR <br />UHFRYHUIURPRWKHUV VXEURJDWLRQ UXOHLQRXUPDQXDO <br />:KHUHUHTXLUHGE\FRQWUDFWRUZULWWHQDJUHHPHQWSULRUWRORVVDQG <br />DOORZHGE\ODZ <br />,QWKHVWDWHRI&RQQHFWLFXW)ORULGD0DU\ODQG1HEUDVND2UHJRQWKH <br />SUHPLXPFKDUJHLVRIWKHWRWDOPDQXDOSUHPLXPVXEMHFWWRDPLQLPXP <br />SUHPLXPRISHUSROLF\ <br />,QWKHVWDWHRI+DZDLLWKHSUHPLXPFKDUJHLVDQGGHWHUPLQHGDV <br />IROORZV7KHSUHPLXPFKDUJHIRUWKLVHQGRUVHPHQWLVRIWKHWRWDO <br />PDQXDOSUHPLXPVXEMHFWWRDPLQLPXPSUHPLXPRISHUSROLF\ <br />,QWKHVWDWHRI/RXLVLDQDWKHSUHPLXPFKDUJHLVRIWKHWRWDOVWDQGDUG <br />SUHPLXPVXEMHFWWRDPLQLPXPSUHPLXPRISHUSROLF\ <br />,QWKHVWDWHRI0DVVDFKXVHWWVWKHSUHPLXPFKDUJHLVRIWKHWRWDO <br />PDQXDOSUHPLXP <br />,QWKHVWDWHRI1HZ<RUNWKHSUHPLXPFKDUJHLVRIWKHWRWDOPDQXDO <br />SUHPLXPVXEMHFWWRDPLQLPXPSUHPLXPRISHUSROLF\ <br />,QWKHVWDWHRI1RUWK&DUROLQDWKHSUHPLXPFKDUJHLVRIWKHWRWDO <br />PDQXDOSUHPLXPVXEMHFWWRDPLQLPXPSUHPLXPRISHUSROLF\ <br />,QWKHVWDWHRI9LUJLQLDWKHSUHPLXPFKDUJHLVRIWKHWRWDOPDQXDO <br />SUHPLXPVXEMHFWWRDPLQLPXPSUHPLXPRISHUSROLF\ <br />1RWDSSOLFDEOHLQ.HQWXFN\1HZ+DPSVKLUHDQG1HZ-HUVH\ <br />7KLVZDLYHUGRHVQRWDSSO\WRDQ\ULJKWWRUHFRYHUSD\PHQWVZKLFKWKH <br />0LQQHVRWD:RUNHUV&RPSHQVDWLRQ5HLQVXUDQFH$VVRFLDWLRQPD\KDYHRUSXUVXH <br />XQGHU06 <br />/LEHUW\,QVXUDQFH&RUSRUDWLRQ <br /> :6386$*URXS+ROGLQJ,QF <br /> <br />Docusign Envelope ID: 08DF66F0-269F-4205-9D7B-EDF7B4AAC0D9