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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 00 03 13 <br />State Description <br />(Ed. 4-84) <br />WV Any party with whom the insured agrees to waive subrogation in a written contract. <br />HI Any party with whom the insured agrees to waive subrogation in a written contract. <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 />Effective Date: Policy No: <br />Insured: <br />Insurance Company: <br />WC 00 03 13 <br />(Ed. 4-84) <br />© 1983 National Council on Compensation Insurance. <br />Countersigned by: <br />Endorsement No.: <br />Premium: <br />oR.N a RAManagmumtDMsian <br />f ° REVIEWED & APPROVED BY. <br />1" Risk Management Specialist <br />V NJ <br />78862138 24-25 CathySon Ent Crystal Wellborn 12/28/2024 7:46:01 PM (CST) I Page 16 of 16 <br />This certificate cancels and supersedes ALL previously issued certificates. <br />