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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 04 02 C <br /> (Ed. 9-14) <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 not enforce our right <br /> against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a <br /> written contract that requires you to obtain this agreement from us.) <br /> You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described <br /> in the Schedule. <br /> The additional premium for this endorsement shall be 5%of the applicable manual premium otherwise due on such remuneration <br /> subject to a policy maximum charge for all such waivers of 5% of total manual premium. <br /> The minimum premium for this endorsement is$350. <br /> This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. <br /> Schedule <br /> Specific Waiver <br /> Person/Organization: City of Santa Ana Risk Management Division <br /> Job Description: Monitoring HAS Account <br /> Waiver Premium: 350.00 <br /> Payroll Subject <br /> Class State to Waiver <br /> 8810 CA 150.00 <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 /> Endorsement Effective: 05/14/2025 Policy No.: STWC66720. Endorsement No.: <br /> Insured: Premium $ <br /> Insurance Company: Oak River Insurance Company / <br /> WC 99 04 02C Countersigned by <br /> (Ed. 9-14) <br />