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TRAVELERS <br />ONE TOWER SQUARE <br />HARTFORD CT 06183 <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 00 03 13 (00) - 016 <br /> <br />POLICY NUMBER: UB-1T88663A <br /> UB-1T885681 <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />ENDORSEMENT <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. <br />We will not enforce our right against the person or organization named in the Schedule. (This <br />agreement applies only to the extent that you perform work under a written contract that requires <br />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 />INCLUDING: <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 <br />contract, executed prior to loss, may execute a waiver of subrogation. <br />However, for purposes of work performed by the employer in Missouri, this <br />waiver of subrogation does not apply to any construction group of <br />classifications as designated by the waiver of right to recover from others <br />(subrogation) rule in our manual. <br />ST ASSIGN:PAGE 1 OF1 <br />Miscellaneous Attachment: M451784 Certificate ID: 22534362 <br />Docusign Envelope ID: 2ECC4EBC-6A30-4243-9E7F-16636E4F3E4BDocusign Envelope ID: 752D86D7-DF31-404C-B79C-D4F81DF70B21