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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA <br />WC 04 03 06 <br />(Ed. 4-84) <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 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 <br />work described in the Schedule. <br />The additional premium for this endorsement shall be % 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, IT'S OFFICERS, AGENTS, EMPLOYEES, <br />REPRESENTATIVES AND VOLUNTEERS <br />AND FIESTA DE CARNIVAL <br />10 FORM <br />ra Stitt shoed-, <br />CGty ��tiornc� <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 Policy No. WC 0568554 Endorsement No. 002 <br />Insured PAUL MAURER Premium $ 138, 137. 00 <br />Insurance Company STAR INSURANCE COMPANY Countersigned by <br />WC 04 03 06 <br />(Ed. 4-84) Hart Forms & Services <br />Reorder No. 14-2420 <br />CA <br />