CTR066205_-_WC_WOS__1_.pdf
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- Attached to
- Master Agreement AZ|CTR066205
- Contract number
- CTR066205
- Issued by
- Arizona
About this file
This document is a Workers Compensation and Employers Liability Insurance Policy Endorsement from Service American Indemnity Company, specifically a Waiver of Right to Recover endorsement for Tohdenasshai Committee Against Family Abuse, Inc. The policy involves the State of Arizona, including its departments, agencies, boards, commissions, officers, officials, agents, and employees, located at 1789 W Jefferson St in Phoenix, AZ.
The policy is effective from 04/16/2025 to 04/16/2026, with the endorsement providing a waiver that prevents the insurance carrier from recovering payments from the named entities in the Schedule. This specific endorsement means the insurance company will not pursue recovery of payments from the State of Arizona and its associated entities for work-related injuries covered under this policy, but only to the extent required by a written contract. The policy number is SATIS0421104, and it is issued by Service American Indemnity Company.
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Text version
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
(Ed. 4-84)
1983 National Council on Compensation Insurance.
WC 00 03 13
(Ed. 4-84) c
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
Endorsement No.Endorsement Effective Date: Policy No.
Carrier Name / Code:
Policy Effective Date: to Premium $
Insured:
DBA:
Countersigned by
Page of
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
SATIS0421104
Service American Indemnity Company
Tohdenasshai Committee Against Family Abuse, Inc.
04/16/2025
04/16/2025 04/16/2026
1 1
The State of Arizona, and its departments, agencies, boards, commissions, officers, officials, agents and employees
1789 W Jefferson St, mail drop 1541 Phoenix, AZ 85007
| Forms |
| WC 00 03 13 (W) (1984-4) Waiver Of Our Right to Recover From Others Endorsement [The State of Arizona, and its departments, agencies, board (AZ)] |
File details come from the government source that posted it. Updated .