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Workers' Compensation and Employers' Liability Policy <br />Named Insured <br />Endorsement Number <br />Insperity, INC. L/C/F <br />KOSMONT & ASSOCIATES, INC. <br />Policy Number <br />19001 Crescent Springs Drive <br />Symbol: RWC Number: C66712679 <br />Kingwood, TX 77339 <br />Policy Period <br />Effective Date of Endorsement <br />10/1/2019 TO 10/1/2020 <br />10/29/2019 <br />Issued By (Name of Insurance Company) <br />Ace American Insurance Co. <br />Insert the policy number. The remainder ofthe information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. <br />CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br />This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the <br />Information Page. <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, but this waiver applies only with respect to bodily <br />injury arising out of the operations described in the Schedule, where you are required by a written contract to obtain this <br />waiver 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 />Schedule <br />(X) Specific Waiver <br />Name of person or organization: <br />CITY OF SANTA ANA <br />20 CIVIC CENTER PLAZA 4TH FLOOR <br />SANTA ANA, CA 92701 <br />( ) Blanket Waiver <br />Any person or organization for whom the Named Insured has agreed by written contract to furnish this <br />waiver. <br />2. Operations: <br />3. Premium: <br />The premium charge for this endorsement shall be INCLUDED percent of the California premium developed on <br />payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations <br />described. <br />��11 rf rll'1RIlii1' - r�'ia"i1 . r111"i1�1►U11�1�7��] <br />WC 99 03 22 <br />4L1&t*= <br />u orize epresen a ive <br />Rime Management DMsian <br />REVIEWED&APPRDVEDBy., <br />'� Risk Management Analyst <br />