GROUP 4 ARCHITECTURE, RESEARCH + PLANNING, INC.

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Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number GROUP 4 ARCHITECTURE RESEARCH PLANNING 211 LINDEN AVE Policy Number SOUTH SAN FRANCISCO, CA 94080-3710 Symbol: RWC Number: C55977306 Policy Period Effective Date of Endorsement 10/1/2023 TO 10/1/2024 10/1/2023 Issued By (Name of Insurance Company) Indemnity Insurance Co. of North America 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. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. 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, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract to obtain this waiver from us. You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. Schedule 1. ( X ) Specific Waiver Name of person or organization: City of Santa Ana 20 Civic Center Plaza Santa Ana, CA 92702 () Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: Santa Ana Library, Project#22575-01. Santa Ana Main Library Renovation WAIVER OF SUBROGATION IN FAVOR OF City of Santa Ana WHEN REQUIRED BY WRITTEN CONTRACT. 3. Premium: The premium charge for this endorsement shall be INCLUDED percent of the California premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. !l�1G �II'il'�I'ii1'-[Riitil►[�7��1�7��] WC 90 03 75 (05/18)