Laserfiche WebLink
Workers' Compensation and Employers' Liability Policy <br />Named Insured <br />Endorsement Number <br />Insperity, INC. L/C/F <br />ORANGE COUNTY'S UNITED WAY ORANGE COUNTY UNITED <br />Policy Number <br />WAY <br />Symbol: RWC Number: C68751949 <br />19001 Crescent Springs Drive <br />Kingwood, TX 77339 <br />Policy Period <br />Effective Date of Endorsement <br />10/1/202o TO 1011/2021 <br />4/14/2021 <br />Issued By (Name of Insurance Company) - <br />Ace American Insurance Co. <br />Insert thepolcy number. The remainder of the Information is to be cum plated only when this endorsement is issued subseg uent to the preparation of the policy. <br />CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <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 />1. (X) Specific Waiver <br />Name of person or organization: <br />City of Santa Ana <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 <br />waiver. <br />2. Operations: <br />RE:Agreement numberA-2021-021-04 <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 />Aufh—onz�lZepfesenFaative <br />Risk Mansgement:DMalpn <br />�f REVIEWED& APPROVED BY: <br />UNIDO <br />R¢k Management Analyst <br />