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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— 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 <br /> work described in the Schedule. <br /> The additional premium for this endorsement shall be See Below%of the California workers' compensation premium <br /> otherwise due on such remuneration. <br /> Schedule <br /> Person or Organization <br /> City of Santa Ana, its City Council, officers, officials, employees, <br /> agents, and volunteers <br /> Job Description <br /> Attention: Community Development Agency, Homeless 20 Civic Center Plaza, <br /> M25, Santa Ana CA 92702 <br /> Specific Waiver is $200 Flat Charge <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 Date:10/01/2 02 5 Policy No. SATI S 0 34 4 9 05 Endorsement No. <br /> Policy Effective Date: 10/01/2 0 2 5 to 10/01/2 0 2 6 Premium $ <br /> Insured: Thomas House Temporary Shelter <br /> DBA: <br /> Carrier Name I Code: Service American Indemnity Company <br /> Countersigned by <br /> WC040306 <br /> (Ed. 4-84) <br /> Page I of 'I <br />