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WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 04 03 06 <br />(Ed, 4-841 <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- <br />CALIFORNIA <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not <br />enforce our right against the person or organization named in the Schedule. (This agreement applies only to the <br />extent that 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 <br />the work described in the Schedule. <br />The additional premium for this endorsement shall be 0.00 % of the California workers' compensation pre- <br />mium otherwise due on such remuneration. <br />Person or Organization <br />ALL PERSONS AND/OR <br />ORGANIZATIONS THAT ARE <br />REQUIRED BY WRITTEN <br />CONTRACT OR AGREEMENT <br />WITH THE INSURED, <br />EXECUTED PRIOR TO THE <br />LOSS, THAT WAIVER OF <br />SUBROGATION BE PROVIDED <br />UNDER THIS POLICY FOR <br />WORK PERFORMED BY YOU <br />FOR THAT PERSON AND/OR <br />ORGANIZATION <br />SCHEDULE: <br />City of Santa Ana <br />Policy Number. WC593205706 <br />Named Insured: All American Asphalt <br />Endorsement Effective Date: 08/01/2019 <br />WC 252 (4-84) <br />WC 04 03 06 (Ed. 4-54) <br />lob Description <br />ALL CALIFORNIA <br />OPERATIONS <br />REFERENCE: <br />Project # 18-6906 / RE: Bristol Street and Edinger <br />Avenue Class II Bike Lanes / <br />& APPROVED <br />1QEMENT DIVISION <br />2 2 2020 <br />M. LAMBERT <br />Page 1 of 1 <br />53W 57 19101ISmnd oo&SSmm X5 lMmmn fhndss 1, 212020 1 o-3511 AM (MT) I Pap I I of 11 <br />