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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA <br />WC 04 03 06 <br />(Ed. 4-84) <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 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 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 policy.) <br />Endorsement Effective 12/1/2017 Policy No.PSW0002298 <br />Insured Insurance Company <br />Johnson -Frank & Associates, Inc. RLI Insurance Company <br />Countersigned By <br />Endorsement No. <br />©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />REVIEWED BY: EUNICE HEREDIA (PG OF ) <br />39024082 1 12/17-18 GL/AUTO/EXCESS/WC/PL I Donna Esquivel 1 11/30/2017 10:01:31 AM (PST) I Page 5 of 5 tv to <br />