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POLICY NUMBER: WCA204889510 <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> WC 42 03 04 B 06 14 <br /> TEXAS WAIVER OF OUR RIGHT TO RECOVER FROM <br /> OTHERS ENDORSEMENT <br /> This endorsement applies only to the insurance provided by the policy because Texas 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, but 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 written <br /> 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 /> 1. ( ) Specific Waiver <br /> Name of person or organization <br /> (X ) Blanket Waiver-Any person or organization as required in writing by contract or agreement prior to loss. <br /> 2. Operations: <br /> "All Texas Operations" <br /> 3. Premium: <br /> The premium charge for this endorsement shall be 2 percent of the premium developed on payroll in connection <br /> with work performed for the above person(s)or organization(s) arising out of the operations described. <br /> 4. Advance Premium: <br /> $0.00 <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 /> Endorsement Effective Policy No. Endorsement No. <br /> 01/01/2026 WCA2048895 10 <br /> Insured Premium <br /> FCS International, Inc. <br /> Insurance Company: Countersigned by <br /> Great Divide Insurance Company <br /> WC 42 03 04 B 06 14 ©Copyright 2014 National Council on Compensation Insurance,Inc.All Rights Reserved. Page 1 Of 1 <br />