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DocuSign Envelope ID:42768609-3F6E-4668-8792-E66DBE7E5727 <br /> 31 <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 /> 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 /> Schedule <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$250 per policy. <br /> Issued by: Liberty Insurance Corporation 21814 <br /> For attachment to Policy No WA7-62D-094060-013 Effective Date Premium$ <br /> WC 00 03 13 © 1983 National Council on Compensation Insurance, Inc. Page 1 of 1 <br /> Ed. 4/1/1984 <br />