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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 <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: <br /> Address: AL, AR, CO, CT, FL, GA, IA, ID, IL, IN, KS, LA, MD, MI, MN, MO, MS, INC, NY, OK, OR, <br /> PA, RI, SC, TN, VA <br /> Description of Waiver: Any person or organization for whom the Named Insured has agreed by written <br /> contract executed prior to loss. <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 07/01/2025 Policy No. 9016877001 Endorsement No. <br /> Insured Premium <br /> Insurance Company Countersigned by <br /> WC 00 03 13 <br /> (Ed. 4-84) <br /> ©1983 National Council on Compensation Insurance. <br /> Page 1 of 1 <br /> 9016877001 <br /> Sentry Casualty Company <br /> 1 00002 0000000000 21179 0 N 85847514-b51d-454c-a68e-be75ff5ffc32 <br />