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Workers' Compensation and Employers' Liability Policy <br /> Named Insured Endorsement Number <br /> CIRCLEPOINT <br /> 1625 CLAY ST STE 700 <br /> OAKLAND, CA 94612-1565 <br /> Policy Number <br /> Symbol:WLR Number: C74068091 <br /> Policy Period Effective Date of Endorsement <br /> 10/01/2025 TO 10/01/2026 10/16/2025 <br /> Issued By(Name of Insurance Company) <br /> Indemnity Insurance Company of North America <br /> Insertthe policy number.The remainder of the information isto be completed only whenthis 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. <br /> of 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 <br /> written contract to obtain this waiver from us. <br /> You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the <br /> work described in the Schedule. <br /> Schedule <br /> 1. ( X ) Specific Waiver <br /> Name of person or organization: <br /> City of Santa Ana <br /> P.O. Box 1988 <br /> 20 Civic Center Plaza (M-30) <br /> Santa Ana, CA 92702 <br /> ( ) 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 /> Ref:Santa Ma On-call Environmental 2023,Circlepoint project no.5725 <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 /> -P <br /> Authorized Agent <br /> WC 90 03 75 (05/18) <br />