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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04 03 06 <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 <br />otherwise due on such remuneration. <br />Person or Organization <br />CLERK OF THE CITY COUNCIL <br />CITY OF SANTA ANA <br />20 CIVIC CENTER PLAZA (M-30) <br />P.O. BOX 1988 <br />SANTA ANA, CA 92702-1988 <br />5 % of the California workers' compensation premium <br />Schedule <br />Job Description <br />$375,375 x 8742 <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 O s / 17 / 22 <br />Insured WESTERN A/V <br />WC 04 03 06 <br />(Ed.4-84) <br />Policy No. 92 MWF673 9 Endorsement No. <br />Insurance Company State Farm Fire and Casualty Company <br />Countersigned By <br />wd Meag m tonxim <br />RttitEvm6 Mxew®er. <br />rr kM1L ix1.10m. lAdi <br />1 UU//22 124262.2 U1-26-2019 <br />