Terrasystems_Southwest_Inc_-_Policy___1005927.pdf
PDF 65 KB Posted
- Attached to
- Master Agreement AZ|CTR043289
- Contract number
- CTR043289
- Issued by
- Arizona
About this file
This document is a Workers Compensation and Employers Liability Insurance Policy Endorsement issued by CopperPoint General Insurance Company for Terrasystems Southwest Inc, specifically involving the State of Arizona. The endorsement provides a waiver of subrogation for the State of Arizona, including its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the contractor. The policy is dated 12/21/2020 with Policy No. 100597 and Endorsement No. 14.
The document outlines a contractual agreement that prevents the insurance company from recovering payments from the specified state entities for work-related injuries. The endorsement effectively protects the State of Arizona and its associated organizations from potential recovery actions by the insurance provider. The premium for this endorsement is $100, and it is specifically scoped to apply only when work is performed under a written contract that requires such a waiver. The endorsement is limited in its application and does not extend benefits to parties not explicitly named in the schedule.
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Text version
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
(Ed. 4-84)
WC 00 03 13
(Ed. 4-84)
© 1983 National Council on Compensation Insurance.
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
State Blanket/Schedule/State
AZ STATE
State Waiver: 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.
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.)
12/21/2020Endorsement Effective 1005927Policy No. 14Endorsement No.
Terrasystems Southwest IncInsured 100 Premium $
CopperPoint General Insurance CompanyInsurance Company Countersigned by
File details come from the government source that posted it. Updated .