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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 43 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy.We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be_% of the California workers' compensation premium otherwise due on such remuneration. Schedule WAIVER OF SUBROGATION IN FAVOR OF The City of Santa Ana, its officers, employees, agents, volunteers and representatives AS RESPECTS OF JOB PERFORMED BY PACIFIC COASTCABLING, INC AS REQUIRED BY WRITTEN CONTRACT. Person or Organization City of Santa Ana Risk Management Division 20 Civic Center Plaza 4th Floor Santa Ana, CA 92702 Job Description Notes: 1. This endorsement may be used to waive the company's right of subrogation against named third parties who may be responsible for an injury. 2. The sentence in( )is optional with the company. It limits the endorsement to apply to specific jobs of the insured,and only to the extent that the insured is required to obtain this waiver. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 12/16/2024 Policy No.WC 69373110 CA Endorsement No. Insured ADP TotalSource DE IV, Inc. Insurance Company AIU Insurance Company 5800 Windward Parkway Alpharetta,GA 30005 L/C/F: PACIFIC COAST CABLING, INC 20717 PRAIRIE ST C Chatsworth,CA 913110000 Countersigned by t a` ©1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual ©2001.