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Workers' Comaensatlon and Emolovars' Llability Poliry <br />-Named Insured <br />Endorsement Number <br />COM_CASTCORPORATION <br />17QI JOHN F. KENNEDY BOULEVARD <br />49TH FLOOR <br />policy Number <br />Symbol: WLR Policy: 068917980 <br />Policy period. <br />Effective Data of Endnraemant <br />12/01/2021-1210112022 <br />Iganarl. By INamo of I"hurannn rmmhsnyl ACE American Insurance Company <br />.Insert the.policy number. The remainder of the mformailon Is to be completed onl when this endbrsemont is Issued subsequent to the preparation of the olio . <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 $.A. of <br />the Information Page. <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, but this waiver applies only with respect <br />to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract <br />to obtain this 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: City of Santa Ana, officers, oftioials, agents, employees, and volunteers <br />2. Operations: <br />3. Premium: <br />The premium charge for this endorsement shall be percent of of the California premium developed on payroll <br />In connection with work performed for the above person(s) or organization(s) arising out of the operations <br />described, <br />4. Minimum Premium: <br />WC 90 03 75 (05/1 S) <br />Authorized Representative <br />m. WhMrn�gnne3Dirimt <br />,�. R REviEwm&APPRcvEDft <br />Risk ManagementAnalyst <br />