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WORKERS COMPENSATION <br />AND <br />ORE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD, CT 06183 <br />ENDORSEMENT WC996376( A)— 001 <br />POLICY NUMBER: IM -3290T63 <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 03.00 % of the California workers' compensation pre- <br />mium. <br />Schedule <br />Person or Organization Job Description <br />ANY PERSON OR ORGANIZATION FOR <br />WHICH THE INSURED HAS AGREED <br />BY WRITTEN CONTRACT EXECUTED <br />PRIOR TO LOSS TO BURNISH THIS <br />WAIVER. <br />City of Santa Ana, its appointed and elected officers, officials, and employees <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 poflcy.) <br />Endorsement Effective <br />Insured JLee Engineenng, Inc, <br />Insurance Company <br />Policy No. UB329OT632 Endorsement No. <br />Premium <br />Countersigned by Leslie Pancoast <br />DATE OF ISSUE: ST ASSIGN: Page t of t <br />