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Workers' Compensation and Employers' Liability Policy <br />Named Insured <br />Endorsement Number <br />GREEN DEMOLITION CONTRACTORS INC. <br />4840 S ST LOUIS AVE SUITE 100 <br />Policy Number <br />CHICAGO, IL 60632 <br />Symbol: WLR Number: C51378325 <br />Policy Period <br />Effective Date of Endorsement <br />10/01/2022 TO 10/01/2023 <br />10-01-2022 <br />Issued By (Name of Insurance Company) <br />Indemnity Insurance Co. of North America <br />Insert the policy number. The remainder of tho informalion is to be complaled only when Ibis endorsement is Issued subsequent to the prop aratmn of tha policy. <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce <br />our right against the person or organization named in the Schedule. This agreement applies only to the extent that <br />you perform work under a written contract that requires you to obtain this agreement from us. <br />This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. <br />Schedule <br />ANY PERSON OR ORGANIZATION AGAINST MOM YOU HAVE. AGREED TO WATVR YOUR <br />R1C11T Or' RhICOVERY 1N A WRi T^_EN CONTRACT, PROVIDL:U SUCH CONTRACT WAS <br />EXECUTED PRIOR TO 'I'HE DATE OF I OSS. <br />For the states of CA, UT, TX, refer to state specific endorsements. <br />This endorsement is not applicable in KY, NH, and NJ. <br />The endorsement does not apply to policies in Missouri where the employer is in the construction group of code <br />classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive <br />subrogation rights against public policy and void where one party to the contract is an employer in the construction <br />group of code classifications. <br />For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. <br />16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract <br />Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract <br />for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by <br />liability or workers compensation insurance shall be against public policy and shall be void and unenforceable <br />except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a <br />consolidated or wrap-up insurance program. <br />Authorized Representative <br />WC 00 03 13 (11/05) Copyright 1983-2017, National Council on Compensation Insurance, Inc. All Rights Reserved <br />SAMPLE <br />