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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 42 03 04 B <br />(Ed. 6-14) <br />TEXAS WAIVER OF OUR RIGHT TO RECOVER FROM 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 enforce <br />our right against the person or organization named in the Schedule, but this waiver applies only with respect to bodily <br />injury arising out of the operations described in the Schedule where you are required by a written contract to obtain this <br />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 />(0) Blanket Waiver <br />ANY PERSON OR ORGANIZATION FOR WHOM THE <br />NAMED INSURED HAS AGREED BY WRITTEN <br />CONTRACT TO FURNISH THIS WAIVER <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 <br />connection with work performed for the above person(s) or organization(s) arising out of the operations described. <br />4. Advance Premium: <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 12-31-24 Policy No. 71749276 Endorsement No. <br />Insured CLIFTONLARSONALLEN LLP Premium $ Incl . <br />Insurance Company Chubb Indemnity Insurance Company <br />Countersigned By <br />WC420304B <br />(Ed. 6-14) <br />© Copyright 2014 National Council on Compensation Insurance, Inc. All Rights Reserved. <br />Insured Copy <br />