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TiR�IVEL�RS�, WORKERS COMPENSATION <br /> G AND <br /> ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br /> HARTFORD CT 06183 <br /> ENDORSEMENT WC 99 D3 76(A)- 001 <br /> POLICY NUMBER: UB-6N607935-25-43-G <br /> WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br /> ENDORSEMENT -- CALIFORNIA <br /> (BLANKET WAIVER) <br /> We have the right to recover our payments from anyone liable for an injury covered by this policy.We will not <br /> enforce our right against the person or organization named in the Schedule. <br /> The additional premium for this endorsement shall be 2.00 %of the California workers'compensation pre- <br /> mium. <br /> Schedule <br /> Person or Organization Job Description <br /> City of Santa Ana <br /> 20 Civic Center Plaza #M-23 <br /> Santa Ana, CA 92702 <br /> City of Santa Ana, its City Cotuncil., officers, <br /> officials, employees, agents, and volunteers <br /> This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise <br /> stated. <br /> (The information below is required only when this endorsement is issued subsequent to preparation of <br /> the policy.) <br /> Endorsement Effective Policy No. Endorsement No. <br /> Insured Premium <br /> DATE OF ISSUE: 06-18-25 STASSIGN: Page 1 of 1 <br />