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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />(Ed. 4-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT— CALIFORNIA <br />We have the rightto recover our payments from anyone liable for an injurycovered by this policy. We will not enforce our <br />right against the person ororganization named in the Schedule. (This agreement applies only to the extent that you per- <br />form 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 the <br />work described in the Schedule. <br />The additional premium for this endorsement shall be See Below % of the California workers' compensation premium <br />otherwise due on such remuneration. <br />Schedule <br />Person or Organization <br />City of Santa Ana, its City Council, officers, <br />officials, employees, agents, and volunteers <br />Job Description <br />20 Civic Center Plaza, 4th Floor Santa Ana, CA 92701 DOO: Re <br />Specific Waiver is $200 Flat Charge <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 Date: 02 / 01 / 2 0 2 5 Policy No. SAT I S 04 0 5 0 0 4 Endorsement No. <br />Policy Effective Date: 02/01/2025 to 02/01/2026 Premium $ <br />Insured: Interval House <br />DBA: <br />Carrier Name 1 Code: Service American Indemnity Company <br />Countersigned by <br />WC 04 03 06 <br />(Ed. 4-84) <br />Page 1 of 1 <br />