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Workers Compensation And Employers Liability Insurance <br />CAMPolicy 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 />Any person or organization for which the employer has agreed by written contract, executed prior to loss, may <br />execute a waiver of subrogation. However, for purposes of work performed by the employer in Missouri, this <br />waiver of subrogation does not apply to any construction group of classifications as designated by the waiver <br />of right to recover from others (subrogation) rule in our manual. <br />Schedule <br />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 />The premium charge for the endorsement is reflected in the Schedule of Operations. <br />All other terms and conditions of the policy remain unchanged. <br />;This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers,I <br />jtakes effect on the Policy Effective Date of said policy at the hour stated in said policy, unless another <br />j effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy <br />unless another expiration date is shown below. <br />Form No: WC 00 03 13 (04-1984) <br />Endorsement No; 23; Page: 1 of 1 <br />Underwriting Company: Valley Forge Insurance Company, 151 N Franklin 8t, Chicago, IL 60606 <br />Poli RskM g.1 oral°" <br />%u f%&sew <br />sex m.,wo�„en o.,uia„< <br />Copyright 1983 National Council on Compensation Insurance. <br />