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L4&lz•1:flAurL=PLk era �i <br />BROKER COPY <br />WAIVER OF SUBROGATION <br />HOME OFFICE <br />SAN FRANCISCO EFFECTIVE OCTOBER 1, 2023 AT 12.01 A.M. <br />ALL EFFECTIVE DATES ARE AND EXPIRING OCTOBER 1, 2024 AT 12.01 A.M. <br />AT 12:01 AM PACIFIC <br />STANDARD TIME OR THE <br />TIME INDICATED AT <br />PACIFIC STANDARD TIME <br />AASCSC <br />850 N BIRCH ST <br />SANTA ANA, CA 92701 <br />9100741-23 <br />RENEWAL <br />NA <br />1-81-08-39 <br />PAGE 1 OF 3 <br />ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, <br />IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND <br />WAIVES ANY RIGHT OF SUBROGATION AGAINST, <br />CITY OF SANTA ANA <br />WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS <br />POLICY IN CONNECTION WITH WORK PERFORMED BY, <br />AASCSC <br />IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN <br />PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION <br />OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE <br />EMPLOYER. <br />IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH <br />EMPLOYEES SHALL BE INCREASED BY 03%. <br />NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE <br />OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS <br />POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE <br />HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEI-- _ - -- <br />LIMITATIONS OF THIS ENDORSEMENT. <br />COUNTERSIGNED AND ISSUED AT SAANN FFRRANCISCO: OCTOBER <br />2570 <br />AUTHORIZED REPRESEN'2 TFYfIVE <br />SCIF FORM 10217 (REV.7-2014) <br />4, 2023 /� <br />,� ,Gd- <br />eeaa. <br />� <br />RiekMmcgementDisivlan <br />BEMEwEo&MPROV®BV: <br />Risk Management Spetlalist <br />PRESIDENT AND CEO <br />OLD DP 217 <br />