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WORKERS'COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 04 03 06 <br /> (Ed. 4-84) <br /> WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- <br /> CALIFORNIA <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 0 . 00 % of the California workers' compensation pre- <br /> mium otherwise due on such remuneration. <br /> Schedule <br /> Person or Organization Job Description <br /> ALL PERSONS AND/OR ALL CA OPERATIONS <br /> ORGANIZATIONS THAT <br /> ARE REQUIRED BY <br /> WRITTEN CONTRACT OR <br /> AGREEMENT WITH THE <br /> INSURED, EXECUTED <br /> PRIOR TO THE <br /> ACCIDENT OR LOSS, <br /> THAT WAIVER OF <br /> SUBROGATION BE <br /> PROVIDED UNDER THIS <br /> POLICY FOR WORK <br /> PERFORMED BY YOU FOR <br /> THAT PERSON AND/OR <br /> ORGANIZATION <br /> SCHEDULED: REFERENCE: <br /> City of Santa Ana. Project#24-6907/ RE: Local Street Preventative <br /> Maintenance FY 23-24/ <br /> Policy Number: WC593205710 <br /> Named Insured: All American Asphalt <br /> Endorsement Effective Date: 08/01/2023 RiskMunagementDhislm <br /> REVIEWED&APPROVED BY: <br /> A AC444 <br /> WC 252(4-84) <br /> Risk Management Specialist <br /> WC 04 03 06(Ed.4-84) l <br /> 79714219 ( 23 (01) Standard with $5mm XS 1 Lisseth Medina 1 4/26/2024 10.52.32 AM (PDT) 1 Page 11 of 11 <br />