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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC'04 03 00 <br /> (Ed, 4-84) <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 not enforce <br /> our right against the person or organization named in the Schedule. (This agreement applies only to the extent that <br /> you perform work under a written contract that requires you to,obtain this'agreemont from us,.) <br /> You must rn intain payroll records aoc:urately segregating the remuneration of your employees while eligaged in the <br /> work-.described in the Schedule, <br /> The.additional premium for this endorsement shall be of the California workers`-compensation premium <br /> otherwise due,on such remuneration, <br /> .Schedule <br /> Person or Organization Job Description <br /> CITY OF SANTA ANA RISK CONTRACT- $7,000 CODE. 8868 <br /> MANAGMENT DIVISION <br /> CITY OF SANTA ANA <br /> CITY OF SANTA ANA, <br /> ITS COUNCIL, OFFICERS, <br /> OFFTCALS,EMPLOYRES, AGENTS, <br /> AND VOLUNTEERR <br /> 20 CTVTC CENTER PLAZA <br /> SANTA ANA Chi 9'2701-4058 <br /> This ondorsemont changes the policy to,which it is-attaohe.d and is.effectiue on tho date issued unl oss othorAse slated, <br /> (The information below is required only when this endorsement is issued,subsequent to preparation of thepolicy.) <br /> Endorsement Effective a9/15/24 PollcyNo. 92-TA-J873-6 Endorsement No. <br /> Insured RELAMPAGO DEL CIELO, INC Insurance Company State Farm J'ire .and Casualty Company <br /> Countersigned B:y <br /> WC.04 03 06. <br /> (Ed. 4-84) 1007722 124282.2 01-25-2019 <br />