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Workers'Compensation and Employers'Liability Pal icy <br /> Named Insured Endorsement Number <br /> HERITAGE MUSEUM OF ORANGE COUNTY <br /> 3101 W HARVARD ST <br /> SANTA ANA,CA 92704-3915 <br /> o um Erer <br /> Symbol:WLR Number. C72439776 <br /> policy perlad EffectE�e ata n orsemant <br /> 10/01/2024 TO 10101/2025 05/3012025 <br /> Issued y ame nsurance pmpany �� <br /> Indemnity InsurFanae Company of!North America <br /> nsgrtt is policy num air, hremainder a eInformation s o rn oo ailed on went s endorsement s ss su quent o the prepare an a go y. <br /> This endorsement changes the policy to which it Is attached and is effective on the data 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 of your employees while engaged in the <br /> work described in the Schedule. <br /> Schedule <br /> 1. ( X ) Specific Waiver <br /> Name of person or organization: <br /> GNy d EwN Atr,Me CMy Cnurdl,ofRfas,ollkl.k .apenle and mL.nfnewa <br /> 20 Civic Center Plaza M-25 <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 /> 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($)or organization(s) <br /> arising out of the operations described. <br /> 4. Minimum Premium: INCLUDED '/W1.,! <br /> Authorized Agent <br /> we 90 03 75 (05118) <br />