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TRAVELERS WORKERS COMPENSATION <br />AND <br />OHS TOWIM <br />ORD, CT SQUAU <br />061 EMPLOYERS LIABILITY POLICY <br />HARTFORD, CT 06183 <br />ENDORSEMENT WC 42 03 04 (A) — 001 <br />POLICY NUMBER: XCUB3974T65A <br />TEXAS WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />ENDORSEMENT <br />This endorsement applies only to the insurance provided by the policy because Texas is shown in Item 3.A. of the <br />Information Page. <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, but this waiver applies only with <br />respect to bodily injury arising out of the operations described in the Schedule where you are required by a written <br />contract to obtain this waiver from us. <br />This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. <br />The premium for this endorsement is shown in the Schedule. <br />Schedule <br />1. ❑ Specific Waiver <br />Name of person or organization <br />® Blanket Waiver <br />Any person or organization for whom the Named Insured has agreed by written contract to furnish this <br />waiver. <br />2. Operations: <br />ALL TEXAS OPERATIONS <br />3. Premium: <br />The premium charge for this endorsement shall be 2.0 percent of the premium developed on payroll in <br />connection with work performed for the above person(s) or organization(s) arising out of the operations <br />describe. <br />4. Advance Premium: $ SEE SCHEDULE <br />DATE OF ISSUE: 10 -23 -14 ST ASSIGN: Page 1 of 1 <br />