2023-07-01_GDAT_WC.pdf

06/13/2022

Marsh Affinity a division of Marsh USA Inc.

PO Box 14404 Des Moines, IA 50306-9686

Marsh Affinity

866-237-4079

ADPTotalSource@marsh.com

New Hampshire Insurance Co. 23841

A 07/01/2022 07/01/2023 2,000,000

2,000,000

2,000,000

ADP TotalSource III, Inc.

5800 Windward Parkway Alpharetta, GA 30005 L/C/F:

Gordon-Darby Arizona Testing, Inc.

3001 S. 35TH STREET

Suite 4 Phoenix, AZ 850340000

WC 053416284 AZX

All worksite employees working for GORDON-DARBY ARIZONA TESTING, INC., paid under ADP TOTALSOURCE, INC?s payroll, are covered under the above stated policy.

WAIVER OF SUBROGATION IN FAVOR OF ARIZONA DEPT. OF ENVIRONMENTAL QUALITY AND , THE STATE OF ARIZONA, ITS DEPARTMENTS, AGENCIES, BOARDS, COMMISSIONS, UNIVERSITIES AND ITS OFFICERS, OFFICIALS, AGENTS, AND EMPLOYEES FOR LOSSES ARISING FROM WORK PERFORMED BY OR ON BEHALF OF THE CONTRACTOR AS RESPECTS OF JOB

PERFORMED BY GORDON-DARBY ARIZONA TESTING, INC. AS REQUIRED BY WRITTEN CONTRACT.

Ref Project: All operations subject to federal, state or local government statute ordinance regulation or licensing

Arizona Dept. of Environmental Quality

1110 W. Washington St.

Phoenix, AZ 85007

X

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below.

This endorsement, effective 12:01 AM 07/01/2022, forms part of Policy No. WC 053416284

Issued to: DP TotalSource III, Inc.

10200 Sunset Drive Miami, FL 33173 L/C/F Gordon-Darby Arizona Testing, Inc.

3001 S. 35th Street Suite 4 Phoenix, AZ 85034

By New Hampshire Insurance Co.

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

In favor of:

Arizona Dept. of Environmental Quality , The State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor 1110 W. Washington St.

Phoenix, AZ 85007

Job Description:

All operations subject to federal, state or local government statute ordinance regulation or licensing

This form is not applicable in Kansas for private construction contracts as defined in K.S.A. 16-1801 through K.S.A. 16-1807 or public construction contracts as defined in K.S.A. 16-1901 through 16-1908, except where permitted by statute or other applicable law, such as for use in wrap-up insurance programs.

Any person or organization for which the employer has agreed by written contract, executed prior to loss, may execute a waiver of subrogation. However, for purposes of work performed by the employer in Missouri, this waiver of subrogation does not apply to any construction group of classifications as designated by the waiver of right to recover from others (subrogation) rule in our manual.

This form is not applicable in California, Kentucky, New Hampshire, New Jersey, Texas, or Utah.

WC 00 03 13 Countersigned by

(Ed. 04/84) Authorized Representative