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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY 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 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 0 % of the California workers' compensation premium <br />otherwise due on such remuneration. <br />Person or Organization <br />CITY OF SANTA ANA PUBLIC WORKS AGENCY <br />Notes: <br />Schedule <br />Job Description <br />VARIOUS LOCATIONS IN SANTA ANA, CA <br />1. This endorsement may be used to waive the company's right of subrogation against named third parties who may be <br />responsible for an injury. <br />2. The sentence in ( ) is optional with the company. It limits the endorsement to apply only to specific jobs of the insured, and <br />only to the extent that the insured is required to obtain this waiver. <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 <br />11/21/2011 <br />Insured <br />Southeast Personnel Leasing, Inc <br />(LCF) West Coast Storm, Inc. <br />Policy No. <br />WSLTHPE90176901 <br />Insurance Company <br />CastlePoint National Insurance Company <br />Countersigned By <br />Endorsement No. N/A <br />de W. <br />Page 2 of 2 PAKQ3QM7 <br />