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ENDORSEMENT WC 00 03 13 (00) -
POLICY NUMBER:
EMPLOYERS LIABILITY POLICY
AND
WORKERS COMPENSATION
:$,9(52)2855,*+7725(&29(5)52027+(56(1'256(0(17
001
ONE TOWER SQUARE
HARTFORD CT 06183
UB-7J183014
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule.
SCHEDULE
DESIGNATED ORGANIZATION:
DESIGNATED PERSON:
ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED
BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER.
DATE OF ISSUE: PAGEST ASSIGN: OF 11