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CHA Workers Compensation And Employers Liability Insurance <br />Policy Endorsement <br />This endorsement applies only to the insurance provided by the policy because Utah 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. (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. Our waiver <br />of rights does not release your employees' rights against third parties and does not release our authority as <br />trustee of claims against third parties. <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 />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, <br />takes effect on the Policy Effective Date of said policy at the hour stated in said policy, unless another <br />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 43 03 05 (07-2000) Policy No: WC 7 11636746 <br />Endorsement Effective Date: Endorsement Expiration Date: Policy Effective Date: 12101 /2024 <br />Endorsement No: 133; Page: 1 of 1 Policy Page: 404 of 412 <br />Underwriting Company: American Casualty Company of Reading, Pennsylvania, 151 N Franklin St, <br />Chicago, IL 60606 <br />0 Copyright 2000 National Council on Compensation Insurance, Inc. <br />