CTR066195_-_WC_WOS__1_.pdf
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- Attached to
- Master Agreement AZ|CTR066195
- Contract number
- CTR066195
- Issued by
- Arizona
About this file
This document is a Workers Compensation and Employers Liability Insurance Policy Waiver of Right to Recover from Others Endorsement. The key parties involved include Consolidated Personnel Service, Inc and Eve's Place, Inc, with the primary entity being the State of Arizona and Department of Economic Security. The insurance is provided by State National Insurance Company, with AmWINS Specialty Casualty Solutions, LLC serving as the agency. The endorsement is effective 10/29/2024 and carries the policy number AMX-740-0022-001.
The endorsement specifically outlines the insurance carrier's waiver of subrogation rights against the named entities, primarily the State of Arizona and its various departments, agencies, boards, commissions, universities, officers, officials, agents, and employees. The document indicates this is a standard workers' compensation policy endorsement that prevents the insurance company from seeking recovery of payments from the specified organizations, but only to the extent of work performed under a written contract requiring such an agreement.
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Text version
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
(Ed. 04-1984)
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
Countersigned by:
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)
File No.: Endorsement Effective:
Insured:
Carrier Policy No.:
Premium:
Carrier No.: 30406
Insurance Company: State National Insurance Company Endorsement: WC 00 03 13 Edition: 04/84
Agency: AmWINS Specialty Casualty Solutions, LLC / 1 © Copyright 1984 National Council on Compensation Insurance
10/29/2024 AMX-740-0022-0011
Consolidated Personnel Service, Inc Eve's Place, Inc
The State of Arizona and Dept of Economic Security C/O: myCOI ; 1075 Broad Ripple Ave, Suite 313 Indianapolis, IN 46220
Comments State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees
File details come from the government source that posted it. Updated .