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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
<br />(Ed. 4-84)
<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 enforce our
<br />right against the person or organization named in the Schedule. (This agreement applies only to the extent that you
<br />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 />WHERE REQUIRED BY WRITTEN CONTRACT, PROVIDED THE
<br />CONTRACT IS SIGNED AND DATED PRIOR TO THE DATE OF
<br />LOSS TO WHICH THIS WAIVER APPLIES, IN NO INSTANCE
<br />SHALL. THE PROVISIONS AFFORDED BY THIS ENDORSEMENT
<br />BENEFIT ANY COMPANY OPERATING AIRCRAFT FOR HIRE.
<br />Per Potcv M'n'rni m Waver Premium by stat,,
<br />$500: AL, AR, CA, CO, CT, DC, 10, IL, IN, IA. KS, ME, MD, Mi, MS, MT, NV, NM, OH, OK, OR, PA, ftl,. $0, UT, VT, VA, WA, INV
<br />$250. AK, DE, LA, NY
<br />$100: NC
<br />$50: WI
<br />N/A: AZ, FL, GA, HI, MA, MN, MO, N8, SC, TN, TX
<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 02101/17 Policy No. T10170329 Endorsement No. 5
<br />Insured Rincon Consultants, Inc Policy Effective Date 02/01/17
<br />Insurance Company StarStone National Insurance Company? —�,
<br />Countersigned Sy� `• — + 7
<br />WC 00 03 13
<br />([d. 4-84)
<br />Cppydpht 1983 National Counoil on Comp m.ticn Imurapca.
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