Apply-A-Line LLC 7/26/2021 - Laserfiche WebLink

Attachment Code: D585640 Master ID: 1485069.Certificate ID: 17701530 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 42 03 04 B (Ed. 6-14) TEXAS WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement applies only to the insurance provided by the policy because Texas is shown in Item 3.A. of the Information Page. 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, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule where you are required by a written contract to obtain this waiver from us. This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. The premium for this endorsement is shown in the Schedule. Schedule 1. ( )Specific Waiver Name of person or organization ( X)Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: 3. Premium: The premium charge for this endorsement shall be 2% percent of the premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. 4. Advance Premium: This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 1/1/2021 Policy No. WC 3002388 00 Endorsement No. Insured Frontline Road Safety Holdings, LLC; Stripe-A-Zone, Inc.;Apply-A-Line, LLC; Griffin Pavement Services Premium Insurance Company Countersigned by WC 42 03 04 B ©Copyright 2014 National Council on Compensation Insurance,Inc.All Rights Reserved. Page 1 of 1 (Ed. 06-14) Wolters Kluwer Financial Services I Uniform FormsTM