Laserfiche WebLink
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04 03 06 <br />(Ed.04«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 you <br />perform work under a written coral 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 5_.00% of the California workers' compensation premium <br />otherwise due on suoh remuneration. <br />Person or Organization <br />City of Santa Ana Community <br />Schedule <br />Job Description <br />City of Santa Ana Community Development Agency <br />Attm Tend Eggers <br />333 W. Ocean Blvd., Long Beach, CA B2701 <br />Contract # 2012-05D. City of Santa Ana, its officers, <br />agents, employees and volunteers <br />Al Operations of the Named Insured <br />This endorsement changes the polloy 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 2D17-02.01 <br />Insured <br />Interval House <br />Insurance Company <br />New York Marine and General Insurance <br />Company/28746 <br />WC 64 03 66 <br />(Ed. 04.64) <br />policy No. Endorsement No. <br />WC2017DO005078 <br />Countersigned By <br />01998 by the Worl aru' Compensation Insurance [Rating Bureau of Caldorns, All rights reserved. <br />