Laserfiche WebLink
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04 03 06 <br />(Ed. 04-84) <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 our right <br />against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under <br />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 work <br />described in the Schedule. <br />The additional premium for this endorsement shall be 5% of the Californiia workers' compensation premium otherwise due on such <br />remuneration. <br />Schedule <br />Person or Organizabon ,lob DesGription <br />City of Santa Ana, its City Council, officers; officials, employees, Approved vendor for the City of Santa Ana. <br />agents, and volunteers ATTN: Audrey Goodson <br />801 W. Civic Center Dr., Suite 200 <br />Santa Ana CA 92701 <br />This endorsement changes the policy to which it is attached and is effective an 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 2l212026 Policy No. TWC4750169 Endorsement No. 3 <br />Insured Kd Education LLC Premium $ 6,773 <br />Insurance Company Technology Insurance Company, Inc. <br />Countersigned by <br />WC 04 03 06 <br />(Ed. 04-84) <br />