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Workers' Compensation and Employers' Liability Policy <br />Named Insured <br />Endorsement Number <br />BARRIOS AND ASSOCIATES, LLC <br />701 E CHAPMAN AVE <br />ORANGE, CA 92866-1620 <br />Policy Number <br />Symbol: WLR Number: C72430876 <br />Policy Period <br />Effective Date of Endorsement <br />10/01/2024 TO 10/01/2025 <br />04/02/2025 <br />Issued By (Name of Insurance Company) <br />Indemnity Insurance Company of North America <br />Insertthe policynumber. The remainder of the information isto be completed only when this endorsement is issued subsequent tolhe 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 ofyouremployees while engaged in the <br />work described in the Schedule. <br />Schedule <br />1. (X) Specific Waiver <br />Name of person or organization: <br />Giv of 9eMs Pow, Ile cuv couw,,ifier4 ommzq FmF s.PoeM,vMValw- <br />20 Civic Center Plaza <br />Santa Ana, CA 92701 <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 />City of Santa Ana Police Department <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 />Authorized <br />90 <br />