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Docusign Envelope ID:C101DF94-8EEA-4210-A163-1FB71C9DF46C <br /> Workers Compensation And Employers Liability Insurance CNA <br /> Policy Endorsement <br /> WAIVERTEXAS OF OUR •OENDORSEMENT <br /> This endorsement applies only to the insurance provided by the policy because Texas is shown in Item 3.A. of <br /> the Information Page. <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, but this waiver applies only with <br /> respect to bodily injury arising out of the operations described in the Schedule where you are required by a <br /> written contract to obtain this waiver from us. <br /> This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. <br /> The premium for this endorsement is shown in the Schedule. <br /> Schedule <br /> z 1 . ❑ Specific Waiver <br /> Name of person or organization <br /> RI Blanket Waiver <br /> Any person or organization for whom the Named Insured has agreed by written contract to furnish this <br /> waiver. <br /> 2. Operations: All Texas Operations <br /> 3. Premium: <br /> The premium charge for this endorsement shall be 2% percent of the premium developed on payroll in <br /> connection with work performed for the above person(s) or organization(s) arising out of the operations <br /> described. <br /> 4. Advance Premium: Refer to Schedule of Operations <br /> N <br /> All other terms and conditions of the policy remain unchanged. <br /> 0 <br /> 0 <br /> 0 <br /> This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, ID <br /> takes effect on the Policy Effective Date of said policy at the hour stated in said policy, unless another <br /> effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy H <br /> unless another expiration date is shown below. o <br /> N <br /> H <br /> O <br /> N <br /> M <br /> O <br /> LLt <br /> O <br /> 0 <br /> m <br /> N <br /> O <br /> H <br /> H <br /> O <br /> O <br /> O <br /> Form No:WC 42 03 04 B (06-2014) Policy No:WC 6 79684599 c3 <br /> Endorsement Effective Date: Endorsement Expiration Date: Policy Effective Date: 11/15/2024 <br /> Endorsement No:85; Page: 1 of 1 Policy Page: 449 of 478 <br /> Underwriting Company; American Casualty Company of Reading, Pennsylvania, 151 N Franklin St, <br /> Chicago, IL 60606 <br /> o Copyright 2014 National Council on Compensation Insurance, Inc. All-Rights Reserved. <br />