Laserfiche WebLink
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA <br />N�- 4�1 - <br />(Ed. 4-84) <br />We have the right to recover our payments from anyone liable for an lnjury covered by this poIicy. 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 />JOHNSON-FRANK &,ASSOC) TE <br />4 S, INC: AGREEMENT # A-2011-098 <br />REVIEWED BY: lrl`7,, - EUNICE HEREDIA (PG, 5 of 5) <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The Informallon, below Is required only when this endorsement Is Issued subsequent to preparation of the policy.) <br />Endorsement Effective 12/1/2014 Policy No. PSWO002298 Endorsement No, <br />Insured Insurance Company <br />Johnson -Frank & Associates, Inc. RLI Insurance Company '7 <br />Countersigned By <br />@1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved, <br />CERT NO— 22492120 TMr8.. P,�j-, 11/26/2014 11:55:50 AM (PST) PAg. 5 of 5 <br />