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AM <br />TRAVELERS WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76(00) — 001 <br />POLICY NUMBER: UB7836Y814 <br />WAIVER OF OUR RIGHT TO RECOVER FROM <br />ENDORSEMENT CALIFORNIA <br />(BLANKET WAIVER) <br />We have the right to recover our payments from anyone liable for an injury covered by this <br />policy. We will not enforce our right against the person or organization named in the Schedule. <br />You must maintain payroll records accurately segregating the remuneration of your <br />employees while engaged in the work described in the Schedule. <br />The additional premium for this endorsement shall be 3.00 % of the California workers' <br />compensation premium otherwise due on such remuneration. <br />Schedule <br />Person or Organization Job Description <br />City of Santa Ana Re: Design Engineering A-2011-099, <br />P.O. Box 1988 Construction Engineering A-2014-101. <br />Santa Ana CA 92702 The City of Santa Ana, its officers, <br />employees, and representatives <br />DATE OF ISSUE: 8/23/2016 ST ASSIGN: CA <br />017106 <br />