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DNA Workers Compensation And Employers Liability Insurance <br /> Policy Endorsement <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 <br /> enforce our right against the person or organization named in the Schedule. (This agreement applies only to the <br /> extent that you 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 <br /> the work described in the Schedule. <br /> The additional premium for this endorsement shall be 2% of the California workers' compensation premium <br /> otherwise due on such remuneration. <br /> Schedule <br /> Person or Organization Job Description <br /> City of Santa Ana,its City Counsel,officers,officials,employees,agents and volunteers <br /> 20 Civic Center Plaza, M-43 <br /> Santa Ana CA 92702 USA <br /> All other terms and conditions of the policy remain unchanged. <br /> This endorsement, which forms a part of and is for attachment to the policy issued by the designated <br /> Insurers,takes effect on the Policy Effective Date of said policy at the hour stated in said policy, unless <br /> another effective date (the Endorsement Effective Date) is shown below, and expires concurrently with <br /> said policy unless another expiration date is shown below. <br /> Form No: WC 04 03 06 (04-1984) Policy No:WC 8018834966 <br /> Endorsement Effective Date: Endorsement Expiration Date: Policy Effective Date:04/01/2026 <br /> Endorsement No: 19; Page: 1 of 1 <br /> Underwriting Company: American Casualty of Readings PA 151 N Franklin St, Chicago, IL 60606 <br /> Copyright 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br /> From the WCIRB's California Workers' Compensation Insurance Forms Manual c 2001. <br />