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Docusign Envelope ID:C101DF94-8EEA-4210-A163-1FB71C9DF46C <br /> CNA Workers Compensation And Employers Liability Insurance <br /> Policy Endorsement <br /> UTAH WAIVER,OF SUBROGATION ENDORSEMENT <br /> This endorsement applies only to the insurance provided by the policy because Utah 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. {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. Our waiver <br /> of rights does not release your employees' rights against third parties and does not release our authority as <br /> trustee of claims against third parties. <br /> Schedule <br /> w <br /> z Any Person or Organization on whose behalf you are required to obtain this waiver of our right to recover <br /> from under a written contract or agreement. <br /> 0 <br /> All other terms and conditions of the policy remain unchanged. <br /> m <br /> 0 <br /> This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers,; <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 <br /> unless another expiration date is shown below. <br /> 00 <br /> N <br /> a <br /> O <br /> d <br /> d <br /> N <br /> D <br /> 00 <br /> M <br /> A <br /> H <br /> M <br /> d <br /> r7 <br /> N <br /> n <br /> 0 <br /> W1 <br /> N <br /> M <br /> O <br /> W <br /> Q <br /> N <br /> M <br /> N <br /> a <br /> rl <br /> C <br /> C <br /> C <br /> Form No:WC 43 03 05 (07-2000) Policy No:WC 6 79684599 Policy <br /> Endorsement Effective Date: Endorsement Expiration Date: Effective Date: 11/15/2024 <br /> Endorsement No: 87; Page: 1 of 1 Policy Page: 453 of 478 <br /> Underwriting Company:American Casualty Company of Reading, Pennsylvania, 151 N Franklin St, <br /> Chicago, IL 60606 <br /> ®Copyright 2000 National Council on Compensation Insurance, Inc. <br />