APPROVED WC 07.01.22-07.01.23.pdf

10/03/2022

Marsh Affinity a division of Marsh USA Inc.

PO Box 14404 Des Moines, IA 50306-9686

Marsh Affinity

800-743-8130

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 FL XVII, Inc.

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

OZ Engineering, LLC

1711 W GREENTREE DRIVE

Suite 205 Tempe, AZ 852840000

WC 053415386 AZ

All worksite employees working for OZ Engineering, LLC paid under ADP TOTALSOURCE, INC.'s payroll, are covered under the above stated policy. RE: Project Number: BPM004214: TSMO On-Call Consultants

State of Arizona, Arizona Department of Transportation

1739 W. Jackson Street Suite A, MD 100P Phoenix, AZ 85007

X

X

WAIVER OF SUBROGATION IN FAVOR OF CERTIFICATE HOLDER AS RESPECTS OF JOB PERFORMED BY OZ Engineering, LLC AS REQUIRED BY WRITTEN CONTRACT.

a8812 Accepted

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 053415386

Issued to:

ADP TotalSource FL XVII, Inc.

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

OZ Engineering, LLC

1711 W GREENTREE DRIVE

Suite 205 Tempe, AZ 852840000

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:

State of Arizona, Arizona Department of Transportation 1739 W. Jackson Street Suite A, MD 100P Phoenix, AZ 85007

Job Description:

RE: Project Number: BPM004214: TSMO On-Call Consultants

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