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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 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 Job Description <br /> City of Santa Ana, its City Audio Visual Systems <br /> Council, Officers, Officials, Integration <br /> Employees, Agents, and <br /> Volunteers <br /> Water Resources ME <br /> 220 S Daisy Ave Bldg A <br /> Santa Ana, CA 92703 <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 07/28/25 Policy No. 92 MWHI14 6 Endorsement No, <br /> Insured WESTERN A/V Insurance Company State Farm Fire and Casualty Company <br /> 1592 N BATAVIA ST STE 2 <br /> ORANGE CA 92867-3554 <br /> Countersigned By <br /> WC 04 03 06 <br /> (Ed. 4-84) 1007722 124282.2 01-25-2019 <br />