WC Endorsement.pdf
PDF 107 KB Posted
- Attached to
- Master Agreement AZ|CTR070125
- Contract number
- CTR070125
- Issued by
- Arizona
About this file
This document is a Workers Compensation and Employers Liability Insurance Policy endorsement issued by Federal Insurance Company for PG Environmental, LLC, effective January 1, 2021. The endorsement specifically involves the Arizona Department of Environmental Quality, located in Phoenix, Arizona, and includes a waiver of subrogation rights with special provisions for policies or exposures in Missouri.
The endorsement focuses on a waiver of the insurance company's right to recover payments from liable parties for work-related injuries, with the specific condition that this waiver applies only when work is performed under a written contract requiring such an agreement. The policy applies to the named organization (Arizona Department of Environmental Quality) and includes a specific caveat for Missouri-based work, where the waiver does not apply to certain construction classification groups as designated in the insurance company's manual. The policy premium is listed as "Incl." (included), and the policy number is 71754106.
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Text version
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.)
Endorsement Effective 01-01-21 Policy No. 71754106 Endorsement No.
Insured PG ENVIRONMENTAL, LLC Premium $ Incl.
Insurance Company Federal Insurance Company
Countersigned By
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
ARIZONA DEPARTMENT OF
ENVIRONMENTAL QUALITY
1110 W WASHINGTON ST
PHOENIX, AZ 85007
For policies or exposure in Missouri:
Any person or organization for which the employer has agreed by written contract, executed prior to loss, may execute a waiver of subrogation. However, for purposes of work performed by the employer in Missouri, this waiver of subrogation does not apply to any construction group of classifications as designated by the waiver of right to recover from others (subrogation) rule in our manual.
File details come from the government source that posted it. Updated .