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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 43 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 not enforce <br /> our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you <br /> perform work under a 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 <br /> work described in the Schedule. <br /> The additional premium for this endorsement shall be_% of the California workers' compensation premium otherwise <br /> due on such remuneration. <br /> Schedule <br /> WAIVER OF SUBROGATION IN FAVOR OF City of Santa Ana, its City Council, officers, <br /> officials, employees, agents and volunteers AS RESPECTS OF JOB PERFORMED BY Hinderliter de <br /> Llamas &Associates AS REQUIRED BY WRITTEN CONTRACT. <br /> Person or Organization <br /> City of Santa Ana, its City Council, officers, officials, employees, agents and <br /> volunteers <br /> 20 Civic Center Plaza <br /> Santa Ana, CA 92701 <br /> Job Description <br /> Notes: <br /> 1. This endorsement may be used to waive the company's right of subrogation against named third parties who may be responsible for an injury. <br /> 2. The sentence in( )is optional with the company. It limits the endorsement to apply to specific jobs of the insured,and only to the extent that the <br /> insured is required to obtain this waiver. <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 07/01/2025 Policy No. WC 063530884 CA Endorsement No. <br /> Insured ADP TotalSource DE IV, Inc. Insurance Company AIU Insurance Company <br /> 5800 Windward Parkway <br /> Alpharetta,GA 30005 <br /> L/C/F: <br /> Hinderliter de Llamas&Associates <br /> 120 S State College Blvd Suite 200 `7 <br /> Brea,CA 92821 Countersigned by D f <br /> ©1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved. <br /> From the WCIRB's California Workers' Compensation Insurance Forms Manual ©2001. <br />