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11 � :. • lf1'❑��Fyi�tP7�I_1�17�1f117S�31�F7�1=1=71�Y�/NF7.9:L1i;C+3�rZ�]�IC+lI <br />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 2 % of the California workers' compensation premium <br />otherwise due on such remuneration. <br />Person or Organization <br />City of Santa Ana, its officers and employees <br />Schedule <br />Job Description <br />Jobs performed for any person or organization that you <br />have agreed with in a written contract to provide this <br />agreement. <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 12/1/2013 Policy No.PSW0002298 Endorsement No. <br />Insured Insurance Company <br />Johnson -Frank &Associates, Inc. RLI Insurance Company <br />Countersigned By v <br />©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />CERT NO.: 19492190 Teresa Frank 12/3/2013 11:99:19 AM Page 5 of 5 <br />