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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 you <br /> 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 /> Specific Waiver <br /> Person/Organization: SAWC666825 <br /> Job Description: as per agreement on file <br /> Waiver Premium: NA <br /> Class State Payroll Subject <br /> to Waiver <br /> 8720 NA NA <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: 05/12/2025 Policy No.SAWC666825 Endorsement No.: <br /> Insured: Premium $ <br /> Insurance Company: Berkshire Hathaway Homestate Ins Co <br /> Countersigned by <br /> WC 00 03 13 <br /> (Ed. 4-84) <br /> ©1983 National Council on Compensation Insurance <br />