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TRAVELERS) <br />ONE TOWER SQUARE HARTFORD CT 06183 <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 00 03 13 (00) - 001 <br />POLICY NUMBER: UB-B9717817-26-N2-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 enforce <br />our 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 />DESIGNATED PERSON: <br />DESIGNATED ORGANIZATION: <br />ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY <br />WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS <br />WAIVER. <br />DATE OF ISSUE: 12-04-25 ST ASSIGN:PAGE 1 OF1 <br />Attachment Code: D681894 Master ID: 1529369, Certificate ID: 19861348 <br />Docusign Envelope ID: 458D6D02-0D6B-8C4E-8292-D706A4D93B4D