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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 <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 anyone not named in the Schedule. <br />Schedule <br />Blanket Waiver <br />Person/Organization:Blanket Waiver - Any person or organization for whom the Named <br />Insured has agreed by written contract to furnish this waiver. <br />Waiver PremiumJob Description <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />© 1983 National Council on Compensation Insurance <br />(Ed. 4-84) <br />Countersigned by ____________________________________WC 00 03 13 <br />Insurance Company: Berkshire Hathaway Homestate Ins Co <br />Insured: <br />Endorsement No.: <br />Premium $ <br />All Other States Operations 9.00 <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement Effective: 04/01/2026 Policy No.: FOWC726350 <br />Docusign Envelope ID: 9624BEFC-E18C-8094-83D4-B6529DE9F703