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CNA Workers Compensation And Employers Liability Insurance <br />Policy 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 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 <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 />1. ❑ Specific Waiver <br />Name of person or organization <br />X❑ 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: 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 <br />described. <br />4. Advance Premium: Refer to Schedule of Operations <br />All other terms and conditions of the policy remain unchanged. <br />This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, <br />takes effect on the Policy Effective Date of said policy at the hour stated in said policy, unless another <br />effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy <br />unless another expiration date is shown below. <br />Form No: WC 42 03 04 B (06-2014) Policy No: WC 4 14100059 Policy <br />Endorsement Effective Date: Endorsement Expiration Date: Effective Date: 06/01/2025 Policy <br />Endorsement No: ; Page: 1 of 1 Page: of <br />Underwriting Company: American Casualty Company of Reading, Pennsylvania, 151 N Franklin St, <br />Chicago, IL 60606 <br />° Copyright 2014 National Council on Compensation Insurance, Inc. All Rights Reserved. <br />