Discussion and Consideration of Pay Application #9 – Miron Construction – Tiffin Recreation Center – Motion to Approve — K-3

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 4-84) 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 anyone not named in the Schedule. Schedule All persons and/or organization's that require a Waiver of Subrogation on work you perform for them, subject to the following conditions: 1. The requirement is by written contract executed by you and them prior to the date of accident or loss; and 2. The written contract contains a hold harmless and indemnification provision in that person or organization's favor; and 3. We are the carrier of record providing General Liability coverage for the insured. 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 01-01-2024 Policy No. WZ92023197 Endorsement No. Insured ILTEN'S INC Premium INCL Insurance Company Countersigned by ___________________________________________ WC 00 03 13 (Ed. 4-84) © 1983 National Council on Compensation Insurance.