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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />ITAIVER *F-U11-R-ff1GAT­I­O-RFCO'1 ER FROM OTHERS i <br />CALIFORNIA <br />', <br />WC 04 03 06 <br />(Ed. 04-84) <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 naned 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 5 % of the California workers' compensation premium <br />otherwise due on such remuneration. <br />PERSON OR ORGANIZATION <br />THE CITY OF SANTA ANA, 20 CIVIC <br />CENTER PLAZA, SANTA ANA, <br />CALIFORNIA 92702; ITS OFFICERS, <br />EMPLOYEES, AGENTS AND VOLUNTEERS <br />2320 REDHILL AVE., SANTA ANA, CA <br />92705. <br />SCHEDULE <br />JOB DESCRIPTION <br />IR�CS <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 02-22-19 Policy No. CFI—WK-10000043-02 Endorsement No. 004 <br />Insured MERCY HOUSE LIVING CENTERS Premium $ INCL. <br />Insurance Company Nova Casualty Company <br />Countersigned By <br />1998 by the WorkersCanpensati on Insurance Bating Bureau of California. All rights reserved. (i <br />From the WCIRB's California Workers' Compensation Insurance Forms Manual 1999. <br />r,<;tjnFo <br />