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AW WORKERS COMPENSATION <br />TRAVELERSJ AND <br />ONE TOWER sOVARE EMPLOYERS LIABILITY POLICY <br />HARTFORD, CT 06103 ENf3GRSEMENT WC 42 03 04 (6) ^ 001 <br />POLICYNUMBER: (PTtM-1176A22-0»17) <br />TEXAS WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />ENDORSEMENT <br />This endorsement applies only to the insurance provided by the policy because Texas is shown in Item 3.A. of <br />the Information Fuge, <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 Schadul% bus this waiver applies only with <br />respect to bodily injury arising out of the operations described In the Schedule where you are required by a <br />written contract to obtain this waiver from us. <br />This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. <br />The premium for this endorsement is shown in the Schedule, <br />Schedule <br />4. Specific wdlver <br />Name of person or organization <br />Id Blanket Waiver <br />Any person :or organization for whom the Named Insured has agreed by written contract to furnish this <br />waiver. <br />2, Operations: <br />ALL TEXAS OPERATIONS <br />3, Premium: <br />The premium charge for this endorsemant shall be 2.x:.0 percent of the premium developed on payroll In <br />connection with work performed for the above person(s) or organization(s) arising out of the operations <br />described. <br />4. Advance Premium: SEE SCFtEDT;LE <br />This endorsement changes the policy to which It is attached and Is effective on the date issued unless otherwise <br />stated. <br />(The Information below Is required only when this endorsement is Issued subsequent to preparation of <br />the policy.) <br />Endorsement Effective Polsoy No, Endorsement No. <br />Insured Premium <br />Insurance Company Countersigned by <br />DATE OF ISSUE: 71112017 ST ASSIGN: Page 1 of 1 <br />O Coptidght 2014 National Council on Compensation Insurance, Inc. At Rights Reserved. <br />