Laserfiche WebLink
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 Council, officers, officials, <br />employees, agents, and volunteers <br />Attention: Heidi Chou <br />215 S. Center St. M-85 <br />Santa Ana CA 92701 <br />5 % of the California workers' compensation premium <br />Schedule <br />Job Description <br />Contract: $200 <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 01- 01- 2 5 <br />Insured WESTERN A/V <br />Policy No. 92-Mw-H628-7 Endorsement No. <br />Insurance Company State Farm Fire and Casualty Company <br />Countersigned By <br />WC 04 03 06 <br />(Ed. 4-84) 1007722 124282.2 01-25-2019 <br />