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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br /> (Ed. 4-84) <br /> WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA <br /> We have the right to recover our payments from anyone liable for an injury covered by this policy. We will <br /> not enforce our right against the person or organization named in the Schedule. (This agreement applies <br /> only to the extent that you perform work under a written contract that requires you to obtain this <br /> agreement from us.) <br /> You must maintain payroll records accurately segregating the remuneration of your employees while <br /> engaged in the work described in the Schedule. <br /> The additional premium for this endorsement shall be 0 % of the California workers' compensation <br /> premium otherwise due on such remuneration. <br /> Schedule <br /> Person or Organization Job Description <br /> CITY OF SANTA ANA <br /> ITS OFFICERS, OFFICIALS, EMPLOYEES, <br /> AND VOLUNTEERS <br /> ATTEN: CITY ATTORNEYS OFFICE <br /> 20 CIVIC CENTER PLAZA M-29 <br /> SANTA ANA, CA 92701 <br /> The charge for this endorsement is $ 250 <br /> This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br /> (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br /> This endorsement, effective 05/09/2025 at 12:01 AM standard time, forms a part of <br /> Policy No. EIG 5951816 00 Of the EMPLOYERS PREFERRED INS. CO. <br /> Carrier Code 00920 <br /> Issued to CARPENTER, ROTHANS & DUMONT ILL Endorsement No. <br /> Premium $10,855 <br /> Countersigned at on BY: <br /> Authorized Representative <br /> WC 04 03 06 <br /> (Ed. 4-84) ©1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved. <br />