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CNAWorkers Compensation And Employers Liability Insurance <br />Polic- ---- -- -- -------------- - - - 1-1-1- ------------------------ 1-1-111, --------------------------- "I --------------------- --- --- ----y Endorsement <br />--------------------- * ----------------------------------------- --- ** _. <br />--------- - ----------------- <br />-- — — - - ---------- <br />C=MCM= <br />------------------ <br />------ - - -- _........------------------------------ <br />We <br />..- <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 />Any Person or Organization on whose behalf you are required to obtain this waiver of our right to recover <br />from under a written contract or agreement. <br />0 <br />The premium charge for the endorsement is reflected in the Schedule of Operations. <br />N <br />2 <br />All other terms and conditions of the policy remain unchanged. <br />R <br />m <br />oO <br />K <br />This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers <br />takes effect on the Policy Effective Date of said policy at the hour stated in said policy, unless another <br />effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy <br />unless another expiration date is shown below. <br />......................... .....------------------- ........-..-..-..-----------t <br />Form No: WC 00 03 13 (04-1984) Policy No: WC 6 80023450 <br />Endorsement Effective Date: Endorsement Expiration Date: Policy Effective Date: 01/19/2021 <br />Endorsement No: 3; Page: 1 of 1 Policy Page: 43 of 68 <br />Underwriting Company: Valley Forge Insurance Company. 151 N Franklin St, Chicago, IL 60606 <br />- ----------------- ----- ........... ------ - ------------ ..............-------------------------------------------- ----------------------------- --- - ------------------------------------ <br />Copyright 1983 National Council on Compensation Insurance. <br />