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9/2/2021 <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 0313 <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 <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 <br />Schedule <br />Name: Any person or organization from whom you are required to waive your right to recover <br />under a written contract or agreement in effect prior to any loss or damage <br />Address: <br />Description of Waiver: Any person or organization from whom you are required to waive your right to recover <br />under a written contract or agreement in effect prior to any loss or damage <br />JobID: <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement Effective 11/01/202G <br />Insured Allison Mechanical, Inc. <br />Insurance Company <br />WC 00 03 13 <br />(Ed. 4-84) <br />©1993 National Council on Compensation Insurance <br />Policy NC.g0114876-005 Endorsement No. <br />Premium <br />Countersigned <br />RI��Y1lrgnnd 176ialar <br />flmE &APPeov®t9r, <br />P.nk Management Supervlmr <br />63929429 1 ALLISMEC 1 2020-21 GLI, CAV, and, MC [piimazY ma [ei] Monique dguyen 1 9/2/2021 8:44:12 AM (POT) I Page 9 a <br />e E This certificate cancels and supersedes ALL previously issued certi cates. <br />