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TRAVELERS JW WORKERS COMPENSATION <br /> AND <br /> ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br /> HARTFORD CT 06183 ENDORSEMENT WC 42 03 04( B) — 001 <br /> POLICY NUMBER: UBOX1376922551K <br /> TEXAS WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br /> ENDORSEMENT <br /> This endorsement applies only to the insurance provided by the policy because Texas is shown in Item 3.A. of <br /> the Information Page. <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, but this waiver applies only with <br /> respect to bodily injury arising out of the operations described in the Schedule where you are required by a <br /> written contract to obtain this 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 /> 1• ❑ Specific Waiver <br /> 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 TEXAS OPERATIONS <br /> 3. Premium: <br /> The premium charge for this endorsement shall be 2.00 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 <br /> described.. <br /> 4. Advance Premium: $SEE SCHEDULE <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 <br /> the policy.) <br /> Endorsement Effective Policy No. Endorsement No. <br /> Insured Premium <br /> Insurance Company Countersigned by <br /> ST ASSIGN: Page 1 of 1 <br /> ©Copyright 2014 National Council on Compensation Insurance, Inc.All Rights Reserved. <br />