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Workers' Compensation and Employers' Liability Policy <br />Named Insured <br />Endorsement Number <br />PLUMBERS DEPOT INC. <br />3921 W 139TH ST <br />HAWTHORNE, CA 90250-7404 <br />Policy Number <br />Symbol: RWC Number: C55951378 <br />Policy Period <br />Effective Date of Endorsement <br />10/1/2023 TO 10/1/2024 <br />10/1/2023 <br />Issued By (Name of Insurance Company) <br />Indemnity Insurance Co. of North America <br />Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <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 3.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 <br />respect to bodily injury arising out of the operations described in the Schedule, where you are required by a written <br />contract to obtain this waiver 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 />Schedule <br />1. ( X ) Specific Waiver <br />Name of person or organization: <br />City of Santa Ana <br />215 S. Center St., Bid. J, M-83 <br />Santa Ana, CA 92703 <br />O Blanket Waiver <br />Any person or organization for whom the Named Insured has agreed by written contract to furnish this <br />waiver. <br />2. Operations: <br />WAIVER OF SUBROGATION IN FAVOR OF City of Santa Ana WHEN REQUIRED BY WRITTEN CONTRACT. <br />3. Premium: <br />The premium charge for this endorsement shall be INCLUDED percent of the California premium <br />developed on payroll in connection with work performed for the above person(s) or organization(s) <br />arising out of the operations described. <br />4. Minimum Premium: INCLUDED <br />AyW�ti�d Qg 5 <br />Risk Ma wgMadDivision <br />RenEvuEo & APRw®Br. <br />�. <br />A4ft Acavea v <br />® <br />Risk Management Specialist <br />