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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 <br />the 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 />ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS <br />AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER <br />For policies or exposure in Missouri: <br />Any person or organization for which the employer has agreed by written contract, executed prior to loss, <br />may execute a waiver of subrogation. However, for purposes of work performed by the employer in <br />Missouri, this waiver of subrogation does not apply to any construction group of classifications as <br />designated by the waiver of right to recover from others (subrogation) rule in our manual. <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 08-01-21 Policy No. 71763685 <br />Insured ICMA RETIREMENT CORPORATION <br />Insurance Company Great Northern Insurance Company <br />WC 00 03 13 <br />(Ed. 4-84) <br />a tgn National Council on Compensation Insurance. <br />Countersigned By <br />inwna Copy <br />Endorsement No. <br />Premium $ Incl . <br />RialeMgnagenieettUloialon <br />REwEwEo6 APPRovm Rr: <br />A� Rc+Nesta <br />Risk Management Spenalist <br />