Waiver_of_Subrogation_for_Workers_s_Comp.pdf
PDF 122 KB Posted
- Attached to
- Master Agreement AZ|CTR071425
- Contract number
- CTR071425
- Issued by
- Arizona
About this file
This document is a Workers Compensation and Employers Liability Insurance Policy Endorsement for a Waiver of Right to Recover from Others, issued by State National Insurance Company through AmWINS Specialty Casualty Solutions, LLC. The policy involves Resourcing Edge 4 LLC and Firm Foundation Youth Homes, with The State of Arizona named as the primary certificate holder. The endorsement covers the State of Arizona, including its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees wherever additional insured status is required.
The endorsement is effective from 05/30/2024, with a carrier policy number AMX-316-0067-001 and carrier number 30406. The document specifically outlines a waiver provision that prevents the insurance carrier from recovering payments from parties named in the Schedule, which in this case is The State of Arizona. The policy applies to work performed under a written contract and ensures that additional insureds are covered to the full limits of liability. The file number is ADCS-17-141467, and the endorsement follows the standard WC 00 03 13 form dated 04/1984.
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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
05/30/2024 AMX-316-0067-0011
Resourcing Edge 4 LLC Firm Foundation Youth Homes
The State of Arizona 3003 N Central Avenue Phoenix, AZ 85012
Comments Cert Holder Name continued: The State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees wherever additional insured status is required. Such additional insured shall be covered to the full limits of liability
ADCS-17-141467
File details come from the government source that posted it. Updated .