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WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br />WC 04 03 06 (Ed, 4-94) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - <br />CALIFORNIA <br />This endorsement changes the policy to which it is attached effective on the Inception date of the policy unless a <br />different date is Indicated below. <br />(The lollowing'attaching clause" need be completed only when this endoraemant is issued subsequent to preparation 01 the policy ) <br />This endorsement, effective on 09/30/2006 at 12:01 A M. standard time, forms a pan of <br />(DATE) <br />Policy No. WC 9139459-00 <br />of the <br />Endorsement No, <br />ZURICH AMERICAN INSURANCE COMPANY <br />(NAME OF INSURANCE COMPANY) <br />Issued to Post, Buckley, Schuh & Jernigan, Inc. dibla PBS&J <br />Named Insured Includes EIP Post, Buckley, Schuh & Jernigan, d/b(a PBSBJ f <br />Premium (if any) $ ZJ <br />rWJ <br />Authorized Represenla <br />We have the right to recover our payments from anyone liable for an Injury covered by this policy. We will riot <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 <br />mlum otherwise due on such remuneration. <br />Schedule <br />Person or Organization <br />% of the California workers compensation pre - <br />Job Description <br />The City of Santo Ann, its officers, employees, agents, RE: Santa Ana MU Overlay #10950-01 <br />volunteers and representatives <br />Attn: Tonia Zerba <br />30 Civic Center Plaza <br />Ross Annex M-20 <br />Santo Ann CA 92702 <br />opke; <br />WC 252 (4-84) <br />WC 04 03 00 (Ed. 4-84) <br />Page I of i <br />2,2'd I9bI £Z6 bTL:01 62L2 66S S0£ -IU93-� fS8d:W0bd I0:91 9002-£I-n0N <br />