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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 M <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 <br /> you perform work under a written contract that requires you to.obtain this agreement from us..) <br /> You mu-st maintain payroll redords aac.urately segregating the remuneration of your employees whild engaged in the <br /> work-.described in the Schedule. <br /> The.additional premium for this endorsement shall be s. % of the California workers'.compensation premium <br /> otherwise due on.such remuneration. <br /> :'Schedule <br /> Person or Organization Jab Description <br /> CITY" OF SANTA ANA RISK CONTRACT. -$7,000 CODE. -8".1 <br /> MANAGMENT DIVISION <br /> CITY OF SANTA ANA <br /> CITY OIL SANTA ANA, <br /> ITS COUNCIL, OFFICERS, <br /> OFFICAL$,EMPLOYEES, AGENTS, <br /> AND VOLUNTEERS <br /> 20 CIVIC CENTER PLAZA <br /> SANTA ANA CA 92701-4058' <br /> This endorsement changes the polity to.which it is•ottachad and is offective on tho date issued unless otherwise statod. <br /> (The-information below is required only when this endorsement is i.ssued.subsequent to preparation of thepolicy.) <br /> Endorsement Effective 09/15/24 FolicyNo. 92-TA-0873-6 Endorsement No. <br /> Insured RELAMPAGO DEL CIELO, INC Insuran.ce Company State Farm Fjji e Land Casualty Company <br /> Countersigned By <br /> WC.04 0$OB. <br /> (Ed.4-84) 1007722 124!28�.2 0145-Miq <br />