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<br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICYWC 04 03 06 <br />(Ed. 04-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENTCALIFORNIA <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 3% of the California workers’ compensation premium <br />otherwise due on such remuneration. <br />Schedule <br />Person or OrganizationJob Description <br />City of Santa Ana - City of Santa Ana, its City Council, officers, officials, <br />employees, agents, and volunteers. <br />* Repairs and services their vehicles at: 711 E 17th Street, <br />Santa Ana CA 92701. <br />- Delivering parts purchased to: 215 S Center St., Santa Ana, <br />Ca. 92702 <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 />EndorsementEffective 7/1/2025PolicyNo. 99 WC-00004934-00EndorsementNo. 2 <br />Insured Insurance Company Benchmark Insurance Company <br />Guaranty Chevrolet Motors, Inc <br />______________________________ <br />Countersigned <br />By <br />WC 04 03 06 <br />(Ed. 04-84) <br />