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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 v 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 <br /> right against the person or organization named in the schedule (This agreement applies only to the extent that you per- <br /> form 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 work <br /> described in the Schedule. <br /> The additional premium for this endorsement shall be $0 of the California workers' compensation premium <br /> otherwise due on such remuneration. <br /> SCHEDULE <br /> Person or Organization Job Description <br /> IN FAVOR OF: Project/Job:T13D <br /> City of Santa Ana <br /> Attn:Community Development Agency <br /> 20 Civic Center Plaza(M-25) <br /> Santa Ana,CA 92701 <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: 06/29/2025 Policy No: WC 33-76-171-00 Endorsement No: <br /> insured: G&A Outsourcing,LLC dba:G&A Partners Labor Contractor,for co-employees of: <br /> Straight Talk Clinic Inc <br /> Insurance Company: Zurich-American Insurance Company Countersigned by <br /> WC 04 03 06 <br /> Copyright 1983 National Council on Compensation Insurance �� �' <br />