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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 42 03 04 A <br />(Ed. 1.00) <br />TEXAS WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS 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 irijdry 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 />(C4 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: All Texas Operations <br />3. Premium: Incl. <br />The premium charge for this endorsement shall be 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 />described. <br />4. Advance Premium: Included <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 10 -01 -11 Policy No. WC3994748 Endorsement No. <br />Insured Raba - Kistner Consultants, Inc. Premium$ Included <br />Insurance Company Countersigned by <br />Zurich— American Insurance Co. <br />WC 42 03 04 A (Ed. 1-00) Page 7 of 1 , <br />