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I-IANRtS E ASsoo/ATt°S RPDA 8/4115 AGR Y# THD REVIEWED BY <br />T dRAVELERSJ <br />4142 TOWER SQUARE <br />HARTFORD, C'T' 06133 <br />UiNKE HEEEDIA (7 OF 11) <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 00 03 13 (00)-01 <br />POLICY NUMBER: (PJUB-0158(U36-A-15) <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 any one not named in the Schedule, <br />SCHEDULE <br />DESIGNATED PERSON: <br />DESIGNATED ORGANIZATION: <br />ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED RAR AGRE`GD <br />BY WRITTEN COMACT EXECUTED PRIOR TO LOGS TO FURNISH THIS <br />WAIVER. <br />DATE OF ISS(JE: 07-28-115 ST ASSIGN: <br />