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Aftk <br />TRAVELERS WORKERS COMPENSATION <br />AND <br />ONE TOWER SQUARE <br />HARTFORD, CT 06183 EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 00 03 13 (00)-01 <br />POLICY NUMBER: (PJUB-8166N36-A-1 6) <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 any one not named in the Schedule. <br />SCHEDULE <br />DESIGNATED PERSON: <br />DESIGNATED ORGANIZATION: <br />ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS <br />AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO <br />FURNISH THIS WAIVER. <br />DATE OF ISSUE: 07-28-16 ST ASSIGN: <br />ERF"V I�mm <br />LED. MER DIA (F <br />