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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 03 13 <br /> - _ (Ed 7-09) <br /> WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA <br /> We have the right to recover our payments from anyone liable for an injury covered by this policy.We will <br /> not enforce our right against the person or organization named in the Schedule. (This agreement applies <br /> only to the extent that you perform work under a written contract that requires you to obtain this <br /> agreement from us.) <br /> You must maintain payroll records accurately segregating the remuneration of your employees while <br /> engaged in the work described in the Schedule. <br /> The additional premium for this endorsement shall be$ 100 <br /> Schedule <br /> Person or Organization Job Description <br /> City of Santa Ana, Attention Coverage provided for all leased employees but not <br /> Parks, Recreation, and Community Services Agency subcontractors of: Industrial Medical Support Inc DBA <br /> 20 Civic Center Plaza Amphibious Medics. Client Effective, 08101/2023, Waiver of <br /> Santa Ana CA 92701 Subrogation in favor of certificate holder, as per written <br /> contract, while work is performed at or in: CA - California. <br /> This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated, <br /> (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br /> Endorsement Effective: 0J/01/2025 Policy No.: WC071-00 125-02 5 Endorsement No.: 10220168 <br /> insured: Vensure HR Inc <br /> L/C/F Industrial Medical support Inc DBA Amphibious <br /> Insurance Company: Countersigned by <br /> SUNZ Insurance company <br /> WC 99 03 13 <br /> (Ed. 7-09) <br /> 10220168 I VensureHRInc MCP (CA) WC07100125025 I Karina Rodriguez 03l2012025 12:37:37 PM -05 I Page 2 of 2 <br />