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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 42 03 04 B <br />(Ed. 06-2014) <br />Texas Waiver of Our Right to Recover From Others Endorsement <br />This endorsement applies only to the insurance provided by the policy because Texas is shown in Item 3.A. of the Information <br />Page. <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, but this waiver applies only with respect to bodily injury arising out of <br />the operations described in the Schedule where you are required by a written contract to obtain this waiver from us. <br />This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. <br />The premium for this endorsement is shown in the Schedule. <br />Schedule <br />1. ( x) Specific Waiver <br />City of Santa Ana <br />Risk Management Division <br />20 Civic Center Plaza <br />Santa Ana, CA 92702 <br />( ) Blanket Waiver <br />Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. <br />2. Operations: <br />3. Premium: N/A <br />The premium charge for this endorsement shall be — percent of the premium developed on payroll in connection <br />with work performed for the above person(s) or organization(s) arising out of the operations described. <br />4. Advance Premium: N/A <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: 03/22/2021 Policy No. WC 027115080 Endorsement No. N/A <br />Premium N/A <br />Insured: ADP TotalSource NH XXVIII, Inc. (PEO Company) <br />10200 Sunset Drive <br />Miami, FL 33173 <br />Invengo American Corp (Client of PEO Company) 536 Silicon Drive STE 100 <br />Southlake, TX 76092 <br />Insurance Company: New Hampshire Ins Cc <br />WC420304B <br />(Ed. 06-2014) <br />Countersigned by ' <br />1 of 1 <br />© Copyright 2014 National Council on Compensation Insurance, Inc. All Rights Reserved. <br />HORaN <br />} z <br />a <br />Risk MmWmendDivisian <br />REVIEWED & APPROVED BY.- <br />p R. W&Wd <br />Risk Management Analyst <br />