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Attachment Code: D616078 Master ID: 1514460, Certificate ID: 18906150 <br />TRAVELERSJ� <br />ONE TOWER SQUARE <br />HARTFORD CT 06183 <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 00 03 13 (00) - <br />POLICY NUMBER: UB-BY032268-24-43-G <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <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 shall not operate directly or indirectly to benefit any one not named In the Schedule. <br />SCHEDULE <br />DESIGNATED PERSON: <br />DESIGNATED ORGANIZATION: <br />ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED <br />BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS <br />WAIVER. <br />INCLUDING: <br />ORGANIZATION: ANY PERSON OR ORGANIZATION FOR WHICH THE <br />INSURED HAS AGREED BY WRITTEN CONTRACT, EXECUTED PRIOR TO <br />LOSS TO FURNISH THIS WAIVER. <br />APPROVED <br />By Cynthia Mora at 5:30 pm, Nov 19, 2024 <br />Any person or organization for which the employer has agreed by written contract, <br />executed prior to loss, may execute a waiver of subrogation. However, for purposes of <br />work performed by the employer in Missouri, this waiver of subrogation does not apply <br />to any construction group of classifications as designated by the waiver of right to <br />recover from others (subrogation) rule in our manual. <br />DATE OF ISSUE: 10-21-24 ST ASSIGN: PAGE 1 OFS <br />