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Specific W"IiVell <br />WORKE=RS COMPENSA-10N AND LHPL0- DIS LIABILITY INSURANCL POL.ICv <br />Coate prepared: August 18, 2000 <br />Carrier: Bridgefieid Employers Insurance Company <br />Effective date of endorsement: August 18, 2.009 <br />Policy Number: 0830.39944 <br />Insured: <br />Tri Sure Corporation <br />P.O. Box 653 <br />Auburndale FL 331323-0653 <br />Physical address: <br />709 Pine Road <br />Auburndale FL 3382.3-0000 <br />iNT€NT: WAIVER OF OUR RIGHT TO RECOVER FROM THE OTHERS ENDORSEMENT <br />Farni nu. VAC: 00 0' 13 <br />(5/97) <br />I LIN: 51-14Q814 > <br />We have the right to recover our payments from anyone_ frabfe for at) fnlury coverer) by this pokey. We wil! not enforce our <br />right against the person or organization named in the Schedule. This agreement applies only to tfie extent that you <br />perform work under a written Contract that requires you to obtain this agreement from us. <br />This agreement shall not operate directly or indirectly to benefit anyone not named nt the Schedule. <br />Schedule <br />Indian River County BOCC <br />1.800 27th Street <br />Vero Beach, FL 32960 <br />)ob: Reuse Water Main Extension 131D No 2009046 -UCP No 28:30 <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise Stated <br />Countersigned by: <-_----~�. -.- -�- flute: August It3, 2t11`) <br />Ce: Tri `pure Corporation <br />Herndon & Associates Insurance <br />Include e pyr!ght in eic•nttl <br />of lhl.� Natrnnar (;_i;s6?t. it (l!1 <br />Corirhollsatiml Inv;urarlco� I[-,- <br />WC <br />r-CWC 00 03 13 (5/97) Copyr-_fist 1993 NCCI <br />I <br />fillfl> H"w 1Jl11rtfitfiie,eff'il',4.11�ill' ilfiniilllttfe �. knit n'A 'of "I k:oVi dplititS <br />