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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 <br />(Ed. 04-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />Republic Indemnity Company of America <br />Company Number <br />19739 <br />Insured <br />Pizza My Heart <br />Policy Number <br />157560-23 <br />Endorsement Number <br />17 <br />Endorsement Effective <br />January 21, 2024 <br />Printed On <br />September 19, 2024 <br />WC 00 03 13 <br />(Ed. 04-84) <br />© 1983 National Council on Compensation Insurance. <br />Countersigned by : <br />2 of 2 <br />