Laserfiche WebLink
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 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 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 5 % of the California workers' compensation premium <br /> otherwise due on such remuneration. <br /> Schedule <br /> Person or Organization <br /> CITY OF SANTA ANA <br /> ITS CITY COUNCIL, OFFICERS, OFFICIALS, EMPLOYEES, A6ENIS, <br /> AND VOLUNTEERS <br /> 20 CIVIC CENTER PLAZA <br /> SANTA ANA CA 92701,M-36 <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 01/01/2026 Policy No. 92-TB-Z389-9 <br /> Insured SANTOLUCITO DORE GROUP INC Insurance Company State Farm Fire and Casualty Company <br /> Countersigned By <br /> WC 04 03 06 <br /> (Ed. 4-84) 1007722 124282.2 01-25-2019 <br />