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Workers' Compensation and Employers' Liability Policy <br />Named Insured <br />Endorsement Number <br />Insperity, INC. L/C/F <br />URM TECHNOLOGIES, INC <br />Policy Number <br />19001 Crescent Springs Drive <br />Symbol: RWC Number: C68766734 <br />Kingwood, TX 77339 <br />Policy Period <br />Effective Date of Endorsement <br />10/1 /2020 TO 10/1 /2021 <br />10/1 /2020 <br />Issued By (Name of Insurance Company) <br />Indemnity Insurance Co. of North America <br />Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. <br />191M11701:10Ile\TITIAkT1 ;1:1101&O1I1:aNN:lli110]:7MIX004:aa:101vi[e119:1;1:t:14011Biel:411MILM401111I <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 M-20 <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 />4. Minimum Premium: INCLUDED <br />WC 99 03 22 <br />......................................................... ........ <br />"R'uthonzecT"Represe"'nt"ative� <br />cF IZAManagmentDivisian <br />k4e \'x REVIEWED & APPROVED BY.- <br />V"° <br />--� Risk janagement Analyst <br />