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C 04 03 06 <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY W(Ed.4-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA <br />ble for an <br />njur <br />red <br />oue have the right to right against the recover OUT or organization msfrom amed In the Schedule.t(This agreeement appli Policy 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 />worts described in the Schedule. <br />be <br />The additional premium for this endorsement shall <br />5 0� or the California workers compensation premium <br />otherwise due on such remuneration. <br />Schedule <br />City of Santa Ana, Its officers, employees an agents and representatives are TRAFFIC DATA <br />additional insured's with respect to general liability and auto liability per <br />the attached endorsements or as required by written contract. <br />insurance is primary and Non -Contributory. <br />This endorsement changes the policy to which it is attached and is effedive on the date issued unless "Twise stab policy.) <br />(The information below is required only when this endorsement is issued subsequent to preparation of the p <br />Endorsement Efiedw policy No. 92-CX-Ml79-0 Endorsement No, <br />Insured Insurance Company State Farm General Insurance ComPany <br />AIMTD, LLC <br />751 S WEIR CANYON RD STE 157-158 <br />ANAHEIM, CA 92808 <br />Countersigned By <br />WC 04 03 os REVIEWED &APPROVED pr meC in 0.5 A <br />(Ed. 4-84) BY R15 ANAGEMENT DIVISION <br />202019 <br />M. LAMBERT <br />