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<br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
<br />(Ed. 4-84)
<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 enforce
<br />our right against the person or organization named in the Schedule. (This agreement applies only to the extent that
<br />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 />WHERE REQUIRED BY WRITTEN CONTRACT, PROVIDED THE
<br />CONTRACT IS SIGNED AND DATED PRIOR TO THE DATE OF
<br />LOSS TO WHICH THIS WAIVER APPLIES. IN NO INSTANCE
<br />SHALL THE PROVISIONS AFFORDED BY THIS
<br />BENEFIT ANY COMPANY OPERATING AIRCRAFT FOR HIRE.
<br />Missouri Special Note: Any person or organization for which the employer has agreed by written contract, executed
<br />prior to loss, may execute a waiver of subrogation. However, for purposes of work performed by the employer in
<br />Missouri, this waiver of subrogation does not apply to any construction group of classifications as designated by the
<br />waiver of right to recover from others (subrogation) rule in our manual.
<br />Per Policy Minimum Waiver Premium by State:
<br />AL, AR, CA, CO, CT, DC, HI, ID, IL, IN, IA, K8, ME, MD, MI, MN, M8, MT, NV, NM, OH, OK, OR, PA, RI, 8C, So, UT, VT, WA,
<br />$500: wv
<br />$250: AK, DE, LA, NY, TN, VA
<br />$100: NC (per waiver)
<br />$50: w
<br />NIA: AZ, FL, GA, KY, MA, MO, NE, NH, NJ, TX
<br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise
<br />stated.
<br />(The information below is required only when this endorsement is issued subsequent to preparation of the
<br />policy.)
<br />Endorsement Effective 2/1/2021 Policy No. T10210329 Endorsement No. 10
<br />Insured Rincon Consultants, Inc. Policy Effective Date 2/1/2021
<br />Insurance Company StarStone National Insurance Company
<br />Countersigned By
<br />WC 00 03 13
<br />(Ed. 4-84)
<br />Copyright 1983 National Council on Compensation Insurance.
<br />Rime Managanent DWisian
<br />REVIEWED&APPROVED By:
<br />'� Risk Management Analyst
<br />
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