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Workers'Compensation and Employers'Liability Polley <br /> Named Insured <br /> RIM Group,Inc,LICI1+Kya services,LLC Endorsement Number <br /> I Patio Place,Suite 600 <br /> DubIfn,CA 94569-7983 <br /> Policy Number <br /> Symbol:WLR Number:C57538716 <br /> Policy Parlod F_ffective Date of Endorsement <br /> 07/01/2024 TO o71ot/2o2s 03120/2025 <br /> Issued By(Name of Insurance Company) <br /> ACE American Insurance Company <br /> Insert the polloy number,The mmalndar of the Information is to be completed only when thle endorsement is Issued subsequent to the preparallon of the poflcy. <br /> This endorsement changes the polloy to which it Is attached and Is effective an the date Issued unless othorwlse stated. <br /> CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br /> This endorsement applies only to the Insurance provided by the poflcy because Callfomia Is shown in item 3,A.of the <br /> Information Page. <br /> We have the right.to recover our payments from anyone liable for an injury covered by this policy. We will not <br /> enforce our right against the person or organization named in the Schedule, but this waiver applies only with respect to <br /> bodily Injury arising out of the operations described in the Schedule, when: you are required by a written contract to <br /> obtain this waiver from us. <br /> You must maintain payroll recants accurately segregating the remuneration of your employees while <br /> engaged in the work described In the Schedule. <br /> Schedule <br /> 1, (X) Speclfic Walver <br /> Name of person or organization: <br /> City of Santa Ants,and its City Council,officers,officials,employees,agents,and volunteers <br /> Attn:Public Works <br /> CIP Engineering <br /> 20 Civic Center Plaza, <br /> Santa,Ana,CA 92701 <br /> ()Blanket Waiver <br /> Any person or organization for whom the Named Insured has agreed by written contractlo <br /> furnish this waiver. <br /> 2. Operations: <br /> 3. Premium: <br /> The premium charge for this endorsement shall be INCLUDED percent of the California premium <br /> developed on payroll in connection with work performed for the above person(s) or organization(s) <br /> arising out of the operations described. <br /> 4. Mlnlmum Premium:INCLUDED <br /> Authorized Representative <br /> WC 90 03 75(05/18) <br />