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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />(Ed. 4-84) <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 <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 />Schedule <br />Person or Organization Job Description <br />City of Santa Ana, their employees, Jobs performed for any person or organization that you <br />officers and directors 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 pol Icy.) <br />Endorsement Effective 2/11/2019 Policy No. PSW0001324 Endorsement No. <br />Insured Insurance Company <br />D. Woolley & gerAnAssociates, Inc.; RLI Insurance Company <br />Harbinger Analytics Group <br />Countersigned By GG <br />©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />50140704 12/19-20 GL/AUT0/8XCE99/WC/PL I Donna 28q ival 17/24/2019 10:10:36 AM (PDT) I Page 5 of 5 <br />