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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will rat enforce <br />our right against the person or organization named in the Schedule, but this waiver applies only with respect to bodily <br />injury arising out of the operations described in the Schedule where you are required by a written contract to obtain <br />this waiver from us. <br />This endorsement shall rat operate directly or indirectly to benefit anyone rat named in the Schedule. <br />The premium for this endorsement is shown in the Schedule. <br />SCHEDULE <br />(X) Specific Waiver <br />Name of person or organization: <br />The City of Santa Ana <br />Its officers, employees, agents and Representatives <br />() Blanket Waiver <br />Any person or organization for whom the Named Insured has agreed by written contract to furnish <br />this waiver. <br />2. Operations: <br />3. Premium <br />The premium charge for this endorsement shall be percent of the premium developed on <br />payroll in connection with work performed for the above person(s) or organiz 6 s) arising out of the <br />operations described. <br />4. Mnimum premium <br />5. Advance Premium <br />All other terms and condition of the policy remain unchanged. <br />(The information below is required to be completed only when this endorsement is issued subsequent to the policy <br />effective date.) <br />Effective , this endorsement fortes part of Policy No. <br />Of <br />Issued to: <br />Endorsement No. <br />AUTHORIZED REPRESENTATIVE <br />