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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04030s <br />(Ed 4-84) <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 <br />our right against the person or organization named in the Schedule. (This agreement applies only to the extent that <br />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 the <br />work described in the Schedule. <br />The additional premium for this endorsement shall be s °k of the California workers' compensation premium <br />otherwise due on such remuneration. <br />Schedule <br />Ealsoff PI-0mantzeticnn <br />TRAFFIC DATA <br />City Of Santa Ana, 20 Civic Center Plaza, Santa Ana, CA 92702 <br />This endorsement changes the policy to which it is attached and is elteclive on the date Issued unless otherwise slated, <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy) <br />Endorcainanr Exemvo POnGy No,02-G6-P853-5 Endorsement No. <br />Insured insurance Company — <br />AIMTD, LLC State Farm General Insurance Company <br />7515 WEIR CANYON RD STE 157-158 <br />ANAHEIM, CA 92808 <br />Countersigned By <br />WC 04 03 06 <br />(Ed 4-84) <br />Roe A1v�.geiwtDiwinn <br />�w®6 Mrxa.�m er <br />?ou >aitx.arc <br />rmxromay�,xam�ianc <br />