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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 <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 LIS.) <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 2 % of the California workers' compensation premium <br />otherwise due on such remuneration, <br />Person or Organization <br />City of Santa Ana, its officers and employees <br />Schedule <br />Job Description: <br />Jobs performed for any person or organization that you <br />have agreed with in a written contract to provide this <br />agreement. <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 podicy.) <br />Endorsement Effective 12/1/2015 Policy No PSWO002298 Endorsement No <br />Insured Insurance Company <br />Johnson -Frank & Associates, Inc. RLI Insurance Company <br />Countersigned By <br />@1998 by the Workers' Compensation Insurance Rating Bureau of California. All rig <br />res <br />IRE-14EWED BY, <br />27t12203 1 12 / I S 16 C4 /A I ,/ .: <br />� X C­ 1,; S /WC/ 2L I f­­ F=%X I I 21/2015 12 36 0 1 .M PSV) I Page 5 aF 5 <br />