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I <br /> THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br /> WAIVER OF OUR RIGHT TO RECOVER FROM <br /> OTHERS ENDORSEMENT - CALIFORNIA <br /> Policy Number: 76 WEG SE9VJW Endorsement Number: 004 <br /> Effective Date: 10/23125 Effective hour is the same as stated on the Information Page of the policy. <br /> Named Insured and Address: Pryme Infil Inc <br /> 853 COTTING CT STE D <br /> VACAVILLE CA 96688 <br /> We have the right to recover our payments from anyone liable for an Injury covered by this policy. We will not enforce our <br /> right against the person or organization named in the Schedule. (This agreement applies only to the extent that you <br /> 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 work <br /> described in the Schedule. <br /> The additional premium for this endorsement shall be 5%of the California workers' compensation premium otherwise due <br /> on such remuneration. <br /> SCHEDULE <br /> Iverson or Organization Job Description <br /> The City of Santa Ana (its City Council, Officers, 3 <br /> Employees,Agents, and Volunteers), 20 CIVIC CENTER <br /> PLZ,SANTA ANA,CA,92701 <br /> Countersigned by � <br /> Authorized Representative <br /> Form WC 04 03 06 (1) Printed in U.S.A. <br /> Process Date. 10123126 Policy Expiration Date:03/01/26 <br /> I <br />