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J , <br />WORKERS COMPENSATION <br />TRM i 4 <br />On TOWER sQUARR <br />EMPLOYERS LIABILITY POLICY <br />HARTPORD, CT 06108 <br />ENDORSEMENT WC 43 03 05 (00) <br />POLICY NUMBER, '(PJUB-1196A22-0-17) <br />UTAH WAIVER OF SUBROGATION ENDORSEMENT <br />This endorsement applies only to the Insurance provided by the policy because Utah is shown in Item 3.A,of the <br />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 shelf not operate directly or indirectly to benefit anyone not named in the Schedule. Our waiver of <br />rights does not release your employees' rights against third parties and does not release our authority as trustee <br />of claims against third parties. <br />Schedule <br />Designated Person: <br />Designated Organization: <br />ANY PERSON OR ORGANT..&ATION FOR WHICH THE INSURED HAS AGREED <br />BYWRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS <br />WAIVER, <br />DATE OF ISSUE; 7/112017 ST ASSIGN, Page 1 of 1 <br />