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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 79 <br />WAIVER OFOUR RIGHT T0RECOVER FROM OTHERS ENDORSEMENT <br />'CAL|R0RN|A <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will <br />not enforce our right against the person or organization named in the Schedule. (This agreement applies <br />only tothe extent that you perform work under written contract that requires you to obtain this agreement <br />----- from ua.) <br />~~~~~ You must maintain payroll records accurately segregating the remuneration of your onnp|oyooa vvhi|o en- <br />gaged in the work described in the Schedule <br />. <br />The additional premium for this ondonaonnont is $ O <br />Schedule <br />Person erOrganization <br />City of Santa Ana <br />Job Description <br />This endorsement changes the policy to which it is attached and is effective on the date issued un|oaa <br />otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of <br />the policy.) <br />Endorsement Effective 08/28/2025 <br />Policy Effective 10/30/2024 <br />Insured PROFESSIONAL SPORTS FIELD <br />MAINTENANCE, INC <br />Endorsement No. 0002 <br />Premium $49.00 <br />Insurance Company Ohio Security Insurance Company <br />Countersigned by <br />WC88O879 <br />(Ed.01'13) <br />� uOl3Liberty Mutual Insurance <br />19291 <br />