Laserfiche WebLink
THIS FORM APPLIES ONLY TO THE FOLLOWING STATE(S) IF COVERED BY YOUR POLICY. IF A <br />STATE IS NOT LISTED BELOW, THIS FORM DOES NOT APPLY IN THAT STATE. <br />AL, AZ, CA, DE, FL, GA, IL, IN, LA, MD, MI, MS, MO, NC, NJ, PA, SC, TN, TX, VA, WV <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 06/01/2023 Policy No. LDS4068227 Endorsement No. <br />Insured Premium $ Included <br />Insurance Company Safety National Casualty Corporation <br />Countersigned By ________________________________ <br />WC 00 03 13 (04 84) <br />© 1983 National Council on Compensation Insurance. <br />Page 1 of 1 <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 <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 anyone not named in the Schedule. <br />SCHEDULE <br />WHERE A WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS IS REQUIRED BY WRITTEN CONTRACT, <br />SUCH ADDITIONAL ENTITIES SHALL BE CONSIDERED AUTOMATICALLY SCHEDULED BY THE <br />COMPANY. <br />INDIVIDUALLY SCHEDULED WAIVERS SHALL NOT BE CONSTRUED TO OVERRIDE NOR NEGATE THIS <br />BLANKET WAIVER. <br />DocuSign Envelope ID: C14B88B2-42FC-400D-9764-0018C8A200FE