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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 43 03 06 <br />(Ed. 4-V <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 <br />enforce our right against the person or organization named in the Schedule. (This agreement applies only to the <br />extent that 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 <br />the work described in the Schedule. <br />The additional premium for this endorsement shall be 5% of the California workers' compensation premium <br />otherwise due on such remuneration. <br />Schedule <br />Person or Organization <br />City of Santa Ana <br />Risk Management Division <br />20 Civic Center Plaza <br />Santa Ana, CA 92702 <br />Job Description: <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 07/01/2022 Policy No. WC 053449479 CA Endorsement No. <br />Insured Insurance Company AIU Insurance Company <br />ADP Totasource DE IV, Inc. <br />5800 Windward Parkway <br />Alpharetta, CA 30005 <br />LC/F: <br />Butler Engineering Inc <br />17822 17th St Ste 404 <br />Tustin, CA 92780 <br />Countersigned by <br />©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />From the WCIRB's California Workers' Compensation Insurance Forms Manual 92001. <br />RiskMan%awdDnislon <br />REVIEWED 6 APPRcV By: <br />c? <br />A+)rcr Auv44 <br />Risk Management Specialist <br />