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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 42 03 04 B <br />POLICY NUMBER: WC 2540616-03 (Ed.6-14) <br />TEXAS WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br />This endorsement applies only to the insurance provided by the policy because Texas is shown in Item 3.A, of the <br />Information Page <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, but this waiver applies only with respect to bodily <br />injury arising out of the operations described in the Schedule where you are required by a written contract to obtain this <br />waiver from us. <br />This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. <br />The premium for this endorsement is shown in the Schedule. <br />Schedule <br />1. (❑) Specific Waiver <br />Name of person or organization <br />(N) Blanket Waiver <br />Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. <br />2. Operations: <br />ALL PERSONS AND/OR ORGANIZATIONS THAT ARE REQUIRED BY <br />WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED <br />PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION <br />BE PROVIDED UNDER THIS POLICY FOR WORK PERFORMED BY YOU FOR <br />THAT PERSON AND/OR ORGANIZATION. <br />3. Premium: <br />The premium charge for this endorsement shall be percent of the premium developed on payroll in <br />connection with work performed for the above person(s) or organization(s) arising out of the operations described. <br />4. Advance Premium: <br />Is <br />"MmginadDm. <br />REma <br />WC 42 03 04 B &Arrx Rc <br />(Ed. 6-14) .�n'. Tau;V&wod <br />© Copyright 2014 National Council on Compensation Insurance, Inc. All Rights Reserved. gapes' n;,¢nt,,,,ye„a,mmuiane <br />