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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />Ed. 04-84 <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 our right <br />against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work <br />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 work <br />described in the Schedule. <br />The additional premium for this endorsement shall be 0.05 % of the California workers' compensation premium otherwise due <br />on such remuneration. <br />Schedule <br />Person Or Organization Job Description <br />City of Milpitas Administration of requestor's FSA and Cobra employee <br />benefits. <br />CITY OF SANTA ANA Benefits Administration ( customer service/data entry) <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 03/05/2025 Policy No. WC PI 891143-001 Endorsement No. 003 <br />Insured Igoe & Company Incorporated Insurance Company The Pie Insurance Company <br />Countersigned By <br />WC 04 03 06 <br />(Ed. 04-84) <br />