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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04 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 <br />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 the <br />work described in the Schedule. <br />The additional premium for this endorsement shall be <br />otherwise due on such remuneration. <br />Person or Organization <br />City of Santa Ana, its City <br />Council, Officers, Officials, <br />Employees, Agents, and <br />Volunteers <br />Water Resources ME <br />220 S Daisy Ave Bldg A <br />Santa Ana, CA 92703 <br />5 % of the California workers' compensation premium <br />Schedule <br />Job Description <br />Audio Visual Systems <br />Integration <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 07/28/25 <br />Insured WESTERN A/V <br />1592 N BATAVIA ST STE 2 <br />ORANGE CA 92867-3554 <br />Policy No. 92 MWH114 6 Endorsement No, <br />Insurance Company State Farm Fire and Casualty Company <br />Countersigned By <br />WC 04 03 06 <br />(Ed. 4-84) <br />1007722 124282.2 01-25-2019 <br />