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WORKERS' COMPENSATION AND EMPLOYEW LIASTUTY INSURANCE: POLICY <br />CALIFORNIA <br />lids endorsement oharsgea the polloy to which it Is attachled offective on the ioception date of the policy uniaos a <br />di.:. rent date is indicated belowr,. <br />lT araga r adauss"neod be WnplslodcragYkMeedse' >ddsina d mbsaqu rd io pyep&sfion etd9,a .l <br />Thda ondomment, effective ori 08101(2013 at t2;01 A;M, standard time, farrns a part of <br />policy No. WC503205M0 <br />of the Zuft American Insurance Company WME of INSUPA04CE COMPANY) <br />Issued to Adi American Asphat <br />We have the right to recover our payments from anyone liable err an Injury hovered by this policy, We will not <br />en&rrce our right against the porson or organizagan named in Che Schedule. (This agreement applies any to the <br />extent that you podarm work under a written contract thatrayuiras you to obtain this agreement from us) <br />you must maintain payroll records oQLurately segregating the renwmeration of your o mptloyeos while engaged in <br />the werk descried in the Schadulo. <br />The addil anal pra dura for this ondors4imvrit shall be <br />miumothrerwisedue onsuch nOfatiart. <br />Person or Organization <br />The City of Santa Ana, 20 Civic Center Plaza, Santa <br />Ana, California 92702; its officers, employees agents <br />and volunteers <br />W<125214-84) <br />We 49 03 06r£ed, 4.&1;) <br />Schedule <br />% of the California workaxV oomposavon pfo- <br />Job Descrfpt on <br />RE: City of Santa Ana - Project #14-6812; Local Street <br />Slurry Seal 2013-2014 <br />ALLPfRS AND/OR OWANIZATONSTRAT Arts ReIUIRED0Y <br />WRITTEN CONTRACT09AGREEMENTirIPTFUTHEhNSURED,EXEOUT J <br />PRIOR T4 T4ht ACCID ENT OR LOSS, THAT WAIVE R 0 F So BROGATION BE <br />PROVIDED U WER THIS POUCY FOR WORK .€tRF0RMEUEly YOU fM <br />THAT PERSONAND/OR OROANUATI ON., <br />Page 9 of Y <br />3584 <br />