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Docusign Envelope ID: FFF6ECOC-4725-4086-B68A-BC5F9FDE53E6 <br /> 22 <br /> TRAVELERS WORKERS COMPENSATION <br /> AND <br /> ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br /> HARTFORD CT 06183 <br /> ENDORSEMENT WC 00 03 13 (00) - 001 <br /> POLICY NUMBER: UB-3R396559-23-I3-G <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 any one not named in the Schedule. <br /> SCHEDULE <br /> DESIGNATED PERSON: <br /> DESIGNATED ORGANIZATION: <br /> ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED <br /> BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS <br /> WAIVER. <br /> Any person or organization for which the employer has agreed by written contract, <br /> executed prior to loss, may execute a waiver of subrogation. However, for purposes of <br /> work performed by the employer in Missouri, this waiver of subrogation does not apply <br /> to any construction group of classifications as designated by the waiver of right to <br /> recover from others (subrogation) rule in our manual. <br /> DATE OF ISSUE: 10-11-23 ST ASSIGN: PAGE 1 OF1 <br />