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PROOF OF INSURANCE (2021) CLOSEDa DATE (MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE �I 09/1212020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER .....ICONTACT NAME MARSH USA, INC PHONE mm FAX 445 ........ 445 SOUTH STREET W.P. Lf9,.. .t1 I.IA+ ,M..RI 1; ...... MORRISTOWN, NJ 07960-6454 E MAIL �,.K?..Oft!65:.......................,,........................,.....,.....,........ _ ............. _...... NG COVERAGE NAIL # IIII INSURER{SI AFFORDL ...............�.,.._....... .....a..............,�_. CN102147003 RAM PROF -20121 610 WRIGH NOC60 INSURER A; HDI Global Insurance Company 41343 INSURER B : Travelers Property Casualty Co. of America INSURED na 25674SIEMENS RAMC 1000 DEERFIELD PARKWAY INSURER c..;.The,Travelers Indemnity Company 25658 BUFFALO GROVE, IL 60089-4513 INSURER D INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: NYC -009189268-48 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR..........._.....................T...... . NSD N!4 .................................................. TYPE OF INSURANCE i L � POLICY NUMBER (MMLICY EFF POLICY EXP LIMITS POLICY A X COMMERCIAL GENERAL LIABILITY GLD11101-12 10/01/2020 1010112021 EACH OCCURRENCE $ 1,000,000 X 'Cts ISL W'YD C''EM m 1,000,000 CLAIMS -MADE OCCUR ECF P uP.........._.I. $ ....... MAM MED XL (Anyon E P, ....o e..erson .... 100,000 0..000 0, . PERSONAL & ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 10,000,000 .............................. X I ,..... POLICY D PRO -LOC JECT PRODUCTS - COMP/OP AG � INCL OTHER $ B AUTOMOBILE LIABILITY TC2J-CAP-7440L34A-TIL-20 10101/2020 10/0112021 COMBINED SINGLE LIMIT (Ea accident)_ __ ___,_ $ 2,000,000 X ANY AUTO BODILY INJURY (Per person) $ N/A �OWN X SCHEDULED BODILY INJURY (Per accident) .................. $ N/A AUTOSED ONLY AUTOS _ X HIRED X NON -OWNED$ kOPERTY DAMAGE NIA —_, AUTOS ONLY AUTOS ONLY (/ �@r:�ccidenaS i A X UMBRELLA OCCUR CUD11102-12 10/01/2020 10/01/2021 EACH ... . ,.0..00,.0_1.0_0 , EXCESS LIAB CS -MADE A. ...O.C.....C...0........R....E.�NCE 2,0..00,0 . 00 $ .. DED ry N RETENTION $ $ RKERS ION UB-8P83929A-20-51-K g X PERH- C AND EMPLOYERS' LIABILITY YNN UB-8P79233A-20-51-R((AZ,SMA, OR, WI) 10/0112020 10/01/2021 STATUTE V,( .................... 1,000,000 ANYPROPRIETOR/PARTNERIEXECUTIVE N / A E L EACH ACCIDENT ,$ ^ ^ B OFFICE CERIMEMBEREXC EXCLUDED? ( ry. ) Mandato m NH """" TWXJ-UB-7440L338-20 OH 10/01/2020 10101/2021 i ASE - EA EMPLOYEE .E..L....DISE............ $ 1,000,000 If yes, descrnbe under DESCRIPTION OF OPERATIONS below """"""$500K LIMIT / $500K SIR"""""" E L DISEASE -POLICY LIMIT $ 1,000,000 A PROFESSIONAL LIABILITY EOD5618801 10/01/2020 10101/2021 1,000,000 Deductible: $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: ALL OPERATIONS SEE ATTACHED CERTIFICATE HOLDER CANCELLATION CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN: CINDY MORTESEN THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN OFFICE OF THE CITY CLERK ACCORDANCE WITH THE POLICY PROVISIONS. 350 MAIN STREET EL SEGUNDO, CA 90245-0989 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee _jir; q �,caK•>r,: n ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN102147003 .................. LOC #: Morristown A4C4n "R" ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED MARSH USA, INC. SIEMENS RAM 1000 DEERFIELD PARKWAY POLICY NUMBER BUFFALO GROVE, IL 60089-4513 CARRIER NAIC CODE ................. ........... _ EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance ............... RE: AEMA-145ACRC - ENGINEERING PLAN CHECK SVCS, CITY OF EL SEGUNDO CITY OF EL SEGUNDO, ITS OFFICIALS, OFFICERS, AGENTS AND EMPLOYEES ARE INCLUDED AS ADDITIONAL INSURED UNDER THE ABOVE REFERENCED GENERAL LIABILITY AND AUTOMOBILE LIABILITY INSURANCE POLICIES AND THE COVERAGE AFFORDED THE ADDITIONAL INSURED UNDER THESE POLICIES SHALL BE PRIMARY AND NON-CONTRIBUTORY INSURANCE TO THE EXTENT THAT A CLAIM ARISES FROM THE NEGLIGENCE OF SIEMENS INDUSTRY, INC. OR ITS SUBCONTRACTORS WITH RESPECT TO ALL OPERATIONS OF THE INSURED BUT ONLY WITH RESPECT TO ALL WORK PERFORMED BY AND ON BEHALF OF THE NAMED INSURED, SIEMENS INDUSTRY, INC. FOR CERTIFICATE HOLDER UNDER CONTRACT THE OWNER AND CONTRACTOR WAIVE ALL RIGHTS AGAINST EACH OTHER AND ANY OTHER CONTRACTOR, SUBCONTRACTORS, SUB -SUBCONTRACTORS, AGENTS, AND EMPLOYEES, FOR DAMAGES OR INJURIES CAUSED BY PERILS TO THE EXTENT COVERED BY INSURANCE, EXCEPT SUCH RIGHTS AS THEY MAY HAVE TO PROCEEDS OF SUCH INSURANCE HELD BY THE OWNER AS A FIDUCIARY. $1,000,000 PROFESSIONAL LIABILITY IS INCLUDED UNDER THE GENERAL LIABILITY POLICY PER PROJECT AGGREGATE APPLIES EXPLOSION, COLLAPSE & UNDERGROUND COVERAGE IS NOT EXCLUDED. CONTRACTUAL LIABILITY IS INCLUDED UNDER THE GENERAL LIABILITY COVERAGE COMPLETED OPERATIONS COVERAGE IS INCLUDED IN THE GENERAL LIABILITY POLICY. IF THESE POLICIES ARE CANCELLED FOR ANY REASON OTHER THAN NON-PAYMENT OF PREMIUM, THE INSURER WILL DELIVER NOTICE OF CANCELLATION TO THE CERTIFICATE HOLDER UP TO 60 DAYS PRIOR TO THE CANCELLATION OR AS REQUIRED BY WRITTEN CONTRACT, WHICHEVER IS LESS ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DATE(MMIDD/YYYY) �m CERTIFICATE OF LIABILITY INSURANCE 0911212020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Mash USA, Inc. 445 SOUTH STREET fONrvr,I:�,l/; (973) 401-5000 L.IFiAu .............__ MARSH USA, INC PH MORRISTOWN, NJ 07960-6454 E4AIL I6............... ....._...... ............. ................__.._. A X UMBRELLA LIAB X OCCUR EXCDEDE�S^LIAB �„RETENT CLAIMS -MADE _ ION$ B WORKERS COMPENSATION C AND EMPLOYERS' LIABILITY YIN ANYPROPRI ETOR/PARTNER/EXECUTIVE B OFFICER/MEMBER EXCLUDED? N� N /A (Mandatory in NH) If yes, describo under DESCRIPTION OF OPERATIONS below CUD11102-12 UB-8P83929A-20-51-K (AOS) UB-8P79233A-20-51-R(AZ, MA, OR, WI) TWXJ-UB-7440L338-20 (OH) ”""""'$500K LIMIT / $500K SIR I I$ 1010112020 10/01/2021 EACHE......... OCCURRENCE GATE..............................................�..$Y............_....., ... AG.. .............. 10101/2020 1`010112021 10101/2020 10/01/2021 10101/2020 10/01/2021 I$ X STH- TATUTE ER" E L EACH ACCIDENT $ E DISEASE - EA EMPLOYEE $ E L DISEASE - POLICY LIMIT $ ( I I I DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: AEMA-145ACRC - ENGINEERING PLAN CHECK SVCS, CITY OF EL SEGUNDO SEE ATTACHED 4,000,000 4,000,000 1,000,000 1,000,000 1,000,000 CERTIFICATE HOLDER CANCELLATION CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN: FLORIZA RIVERA, PW DEPT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 MAIN ST ACCORDANCE WITH THE POLICY PROVISIONS. ELSEGUNDO, CA 90245 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee av��ea+4�atcwax�e� P, ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ....................... ....................INSURER S AFFORDING,COVERAGE _ NAIC #......... CN102147003-RAM-PPA-20121 610 ROLLIN NOC60 INSURER A: HDI Global Insurance Company 41343 INSURED INSURER B : Traveler Property 0 of Amef ca Travelers ua ty I 25674SIEMENS - 1000 EER ELD PARKWAY INSURER c: The Travelers s Indemnity C ............... ........................ ompany,, ,,, , ,,, , 25658 BUFFALO GROVE, IL 60089-4513 INSURER D: INSURER E INSURER F : a COVERAGES CERTIFICATE NUMBER: NYC -008881096-15 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY 'AID CLAIMS. „ ......... ...... TYPE OF INSURANCE .-__ ..._.,-........., .. ..... ....... ILTR IADD�Sy,U,un POLI CYNUMBER .........._.__....__.__.___._ .... POLICY EFF POLICY EXP LIMITS IMM/DD/YYYY) IMMIDD/YYYYf ..... ...........— A COMMERCIAL GENERAL LIABILITY GLD11101-12 1010112020 1010112021 $ 0,0 1 D-AWi ETuWENTC 1 000,000 CLAIMS-MADLX] OCCUR PREMISES IL a occtifrencO $ ..... . _ MED EXP (Any one person) $ .........�.....--. ............m......_ADV .PERSONAL 100,000 & INJURY $ 1,000,000. GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 1,000,000 POLICY X O.CT LOC YIR�E ,PRODUCTS - COMP/OP AGG $ INCL OTHER B AUTOMOBILE LIABILITY TC2J-CAP-7440L34A-TIL-20 1010112020 10101/2021 COMBINED LIMIT $ 2,000,000 X ANY AUTO BODILY INJURY (Per person) $ N/A OWNED BODILY INJURY (Per ............. ASCHOSULED ONLY UT UTOS $ �...LR X....I ATOS ONLY X ER'rn(�AMAGEaocidenl)� N/A OSDONLY ,0 ml A X UMBRELLA LIAB X OCCUR EXCDEDE�S^LIAB �„RETENT CLAIMS -MADE _ ION$ B WORKERS COMPENSATION C AND EMPLOYERS' LIABILITY YIN ANYPROPRI ETOR/PARTNER/EXECUTIVE B OFFICER/MEMBER EXCLUDED? N� N /A (Mandatory in NH) If yes, describo under DESCRIPTION OF OPERATIONS below CUD11102-12 UB-8P83929A-20-51-K (AOS) UB-8P79233A-20-51-R(AZ, MA, OR, WI) TWXJ-UB-7440L338-20 (OH) ”""""'$500K LIMIT / $500K SIR I I$ 1010112020 10/01/2021 EACHE......... OCCURRENCE GATE..............................................�..$Y............_....., ... AG.. .............. 10101/2020 1`010112021 10101/2020 10/01/2021 10101/2020 10/01/2021 I$ X STH- TATUTE ER" E L EACH ACCIDENT $ E DISEASE - EA EMPLOYEE $ E L DISEASE - POLICY LIMIT $ ( I I I DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: AEMA-145ACRC - ENGINEERING PLAN CHECK SVCS, CITY OF EL SEGUNDO SEE ATTACHED 4,000,000 4,000,000 1,000,000 1,000,000 1,000,000 CERTIFICATE HOLDER CANCELLATION CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN: FLORIZA RIVERA, PW DEPT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 MAIN ST ACCORDANCE WITH THE POLICY PROVISIONS. ELSEGUNDO, CA 90245 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee av��ea+4�atcwax�e� P, ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN102147003 LOC #: Morristown ADDITIONAL REMARKS SCHEDULE AGENCY NAMED INSURED MARSH USA, INC SIEMENS RAM 1000 DEERFIELD PARKWAY POLICY NUMBER BUFFALO GROVE, IL 600894513 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance RE: ALL OPERATIONS CITY OF EL SEGUNDO, OFFICE OF THE CITY CLERK IS INCLUDED AS ADDITIONAL INSURED UNDER THE ABOVE REFERENCED GENERAL LIABILITY AND AUTOMOBILE LIABILITY INSURANCE POLICIES AND THE COVERAGE AFFORDED THE ADDITIONAL INSURED UNDER THESE POLICIES SHALL BE PRIMARY AND NOW CONTRIBUTORY INSURANCE TO THE EXTENT THAT A CLAIM ARISES FROM THE NEGLIGENCE OF SIEMENS INDUSTRY, INC OR ITS SUBCONTRACTORS WITH RESPECT TO ALL OPERATIONS OF THE INSURED BUT ONLY WITH RESPECT TO ALL WORK PERFORMED BY AND ON BEHALF OF THE NAMED INSURED, SIEMENS INDUSTRY, INC. FOR CERTIFICATE HOLDER UNDER CONTRACT, THE OWNER AND CONTRACTOR WAIVE ALL RIGHTS AGAINST EACH OTHER AND ANY OTHER CONTRACTOR, SUBCONTRACTORS, SUB -SUBCONTRACTORS, AGENTS, AND EMPLOYEES, FOR DAMAGES OR INJURIES CAUSED BY PERILS TO THE EXTENT COVERED BY INSURANCE, EXCEPT SUCH RIGHTS AS THEY MAY HAVE TO PROCEEDS OF SUCH INSURANCE HELD BY THE OWNER AS A FIDUCIARY COMPLETED OPERATIONS COVERAGE IS INCLUDED IN THE GENERAL LIABILITY POLICY IF THESE POLICIES ARE CANCELLED FOR ANY REASON OTHER THAN NON-PAYMENT OF PREMIUM, THE INSURER WILL DELIVER NOTICE OF CANCELLATION TO THE CERTIFICATE HOLDER UP TO 60 DAYS PRIOR TO THE CANCELLATION OR AS REQUIRED BY WRITTEN CONTRACT, WHICHEVER IS LESS. Page 2 of 2 ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: TC2J—CAP-7440L34A—TIL-20 COMME=RCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ItMANI 1 1114 A71,11 This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE= FORM MOTOR CARRIE=R COVE=RAGE FORM The following replaces Paragraph A.5.. Transfer of required of you by a written contract executed Rights Of Recovery Against Others To Us, of the prior to any "accident" or "lass", provided that the CONDITIONS Section: "accident" or "loss" apses out of the operations 5. Transfer Of Rights Of Recovery Against Oth- contemplated by such contract. The waiver ap- ers To Us plies only to the person or organization desig- We waive any right of recovery we may have nated in such contract. against any person or organization to the extent CA T3 40 02 15 U 2015 The Travelers Indemnity Company. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc, with its permission. HDI GLOBAL INSURANCE COMPANY MANUSCRIPT ENDORSEMENT # 32 Policy Mum ber Named Insured GLD11101-12 SIEMENS CORPORATION Policy Period: Inception (M -D -Y) Expiration (M -D -Y) Effective Date and Time of Endorsement 10-01-2020 10-01-2021 10-01-2020 12:01 a.m. Standard Time at Address of the Insured. This Endorsement Changes The Policy. Please Read It Carefully. This endorsement modifies insurance provided under the fallowing: Commercial General Liability Coverage Form Who is an insured is amended to include as an additional insured any person whom you are required to add as an additional insured or this policy under a written agreement, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions, or 2. The acts or omissions of those acting on your behalf. The insurance coverage provided to such additional insured applies only to the extent required within the written agreement. The insurance coverage provided to the additional insured person shall not provide any broader coverage than you are required to provide to the additional insured person in the written agreement and shall not provide limits of insurance that exceed the lower of the Limits of Insurance provided to you in this policy, or the limits of insurance you are required to provide in the written agreement. The insurance provided to the additional insured by this endorsement is excess over any valid and collectible other insurance, whether primary, excess, contingent, or on any other basis, that is available to the additional insured for a loss we cover under this endorsement. However, if the written agreement specifically requires that this insurance apply on a primary basis, this insurance is primary. If the written agreement specifically requires this insurance apply on a primary and non-contributory basis this insurance is primary to other insurance available to the additional insured and we will not share with thatother insurance. This endorsement shall prevail over additional insured endorsements that may apply under this policy unless required otherwise in the written agreement. Authorized Representative All terms and conditions of the policy remain unchanged. THIS ENDORSEMENT MIDST BE ATTACHED TO A CHANGE ENDORSEMENT WHEN ISSUED AFTER THE POLICY IS WRITTEN. Page POLICY NUMBER: GLD11101-12 This endorsement modifies insurance provided under the following. COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: ANY PERSON OR ORGANIZATION TO THE EXTENT REQUIRED BY WRITTEN CONTRACT u Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "Your work" done under a contract with that person or organization and included in the "products - completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CO 24 04 05 09 O Insurance Services Office, Inc., 2008 Page 1 of 1 13 TRAVELERS " �1i�V ��� WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 00 03 13 (00) - POLICY NUMBER: UB-SP83929A-20-51 -x WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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 PERSON: DESIGNATED ORGANIZATION: ANY PERSON OR ORGANIZATION FOR WHOM A WAIVER OF SUBROGATION 19 REQUIRED BY CONTRACT OR AMMUMM OR PERMIT, BUT COVZRMM IS LIMITED TO THE SCOPE OF THE MM PER1111ORIM BY THE INSURED WIDER SUCH CONTRACT, AGPZXMM OR PERMIT. DATE OF ISSUE: 09-01--20 ST ASSIGN: