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Workers Compensation And Employers Liability Insurance Policy Endorsement
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
The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees
The premium charge for the endorsement is reflected in the Schedule of Operations.
All other terms and conditions of the policy remain unchanged.
This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, takes effect on the Policy Effective Date of said policy at the hour stated in said policy, unless another effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy unless another expiration date is shown below.
WC 6 24588854
Endorsement No: 16; Page: 1 of 1 Policy Page: 59 of 76
Underwriting Company: Valley Forge Insurance Company, 151 N Franklin St, Chicago, IL 60606
Form No: WC 00 03 13 (04-1984) Endorsement Effective Date:
Policy No:
Policy Effective Date: 06/01/2024Endorsement Expiration Date:
Copyright 1983 National Council on Compensation Insurance.
| INSURED |
| CNA, WC |
| COVER LETTER |
| Page 1 |
| CNA89096XX (05-2017): POLICYHOLDER NOTICE - WISCONSIN NOTICE TO THIRD PARTY OF CANCELLATION OR MATER |
| Page 1 |
| POLICYHOLDER NOTICE - FRAUD NOTIFICATION |
| Page 1 |
| Page 2 |
| Page 3 |
| CC031605A: IMPORTANT INFORMATION - CNA INSURANCE PREMIUM AUDIT |
| Page 1 |
| Page 2 |
| G-15257-A: IMPORTANT INFORMATION TO OUR WISCONSIN POLICYHOLDERS |
| Page 1 |
| G-18249-A02 (02-2021): IMPORTANT INFORMATION - IMPORTANT NOTICE TO OUR INSUREDS ARIZONA POSTING NOTI |
| Page 1 |
| G-18998-C48: IMPORTANT INFORMATION KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS |
| Page 1 |
| G-23130-C: IMPORTANT INFORMATION OREGON EMPLOYERS: INTRO TO WORKERS COMPENSATION |
| Page 1 |
| Page 2 |
| Page 3 |
| G-43595-H: IMPORTANT INFORMATION NOTICE TO EMPLOYERS REGARDING MEDICAL PAYMENTS OF NON-DISABLING |
| Page 1 |
| G-83274-K (12-2017): IMPORTANT INFORMATION OREGON SAFETY AND HEALTH LOSS CONTROL SERVICES |
| Page 1 |
| Page 2 |
| G-140370-E (05-2019): PRIVACY POLICY NOTICE |
| Page 1 |
| P-33398-E: WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INFORMATION PAGE |
| Page 1 |
| Page 2 |
| P-33398-E: POLICY INFORMATION - SCHEDULE OF OPERATIONS |
| Page 1 |
| Page 2 |
| Page 3 |
| Page 4 |
| P-33398-E: POLICY INFORMATION - CLASS DESCRIPTION SUMMARY PAGE |
| Page 1 |
| P-33398-E: POLICY INFORMATION - ENDORSEMENT SCHEDULE |
| Page 1 |
| Page 2 |
| P-33398-E: POLICY INFORMATION - NAMED INSURED SCHEDULE |
| Page 1 |
| P-33398-E: POLICY INFORMATION - NAME AND ADDRESS SCHEDULE |
| Page 1 |
| Page 2 |
| Page 3 |
| Page 4 |
| Page 5 |
| PAYMENT PLAN SCHEDULE |
| Page 1 |
| WC 00 00 00 C: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY |
| Page 1 |
| Page 2 |
| Page 3 |
| Page 4 |
| Page 5 |
| Page 6 |
| CC84253A: ARIZONA - EXTENDED CANCELLATION OR NON-RENEWAL NOTICE ENDORSEMENT |
| Page 1 |
| CC80652A: WISCONSIN PARTICIPATING PROVISION |
| Page 1 |
| CNA87380XX (11-2016): NOTICE OF CANCELLATION OR MATERIAL CHANGE ENDORSEMENT |
| Page 1 |
| G-35224-B: INCREASED LIMIT OF LIABILITY ENDORSEMENT |
| Page 1 |
| G-120608-A: YOUR DUTY IF INJURY OCCURS - ENDORSEMENT |
| Page 1 |
| G-120609-A: UNINTENTIONAL ERRORS AND OMISSIONS OR FAILURE TO DISCLOSE - ENDORSEMENT |
| Page 1 |
| G-300657-C: CANCELLATION OR NONRENEWAL ENDORSEMENT |
| Page 1 |
| P-15114-A: PARTICIPATING PROVISION - ARIZONA |
| Page 1 |
| P-39189-A: PARTICIPATING PROVISION - OREGON |
| Page 1 |
| WC 00 01 06 A: LONGSHORE AND HARBOR WORKERS COMPENSATION ACT COVERAGE ENDORSEMENT |
| Page 1 |
| WC 00 02 01 B: MARITIME COVERAGE ENDORSEMENT |
| Page 1 |
| Page 2 |
| WC 00 03 01 A: ALTERNATE EMPLOYER ENDORSEMENT |
| Page 1 |
| Page 2 |
| WC 00 03 08: PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT |
| Page 1 |
| WC 00 03 11 A: VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT |
| Page 1 |
| Page 2 |
| WC 00 03 13: WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT |
| Page 1 |
| WC 00 03 13: WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT |
| Page 1 |
| WC 00 04 14 A (01-2019): 90-DAY REPORTING REQUIREMENT - NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEM |
| Page 1 |
| WC 00 04 19: PREMIUM DUE DATE ENDORSEMENT |
| Page 1 |
| WC 00 04 19 A (08-2022): PART FIVE - PREMIUM AMENDATORY ENDORSEMENT |
| Page 1 |
| WC 00 04 21 F (08-2022): CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT |
| Page 1 |
| WC 00 04 22 C (01-2021): TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT |
| Page 1 |
| Page 2 |
| WC 00 04 24 (01-2017): AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT |
| Page 1 |
| WC 00 04 25 (05-2017) EXPERIENCE RATING MODIFICATION FACTOR REVISION ENDORSEMENT |
| Page 1 |
| WC 02 06 01 C (09-2021): ARIZONA CANCELLATION AND NONRENEWAL ENDORSEMENT |
| Page 1 |
| WC 02 06 03 A: ARIZONA AMENDATORY ENDORSEMENT |
| Page 1 |
| WC 36 03 06: OREGON LIMITS OF LIABILITY ENDORSEMENT |
| Page 1 |
| WC 36 06 01 E: OREGON CANCELLATION ENDORSEMENT |
| Page 1 |
| WC 36 06 02: OREGON CONFIDENTIALITY ENDORSEMENT |
| Page 1 |
| OREGON AMENDATORY ENDORSEMENT |
| Page 1 |
| WC 48 06 01 C: WISCONSIN LAW ENDORSEMENT |
| Page 1 |
| WC 48 06 06 B: WISCONSIN CANCELLATION AND NONRENEWAL ENDORSEMENT |
| Page 1 |
| Page 2 |