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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 />If the following information is not complete, refer to the appropriate Schedule attached to the policy. <br />Insured:willdan Homeland Solutions <br />Producer: Dealey, Renton & Associates <br />Policy Number WZP81007462 <br />Effective Date 11/2/2012 <br />Schedule <br />Person or Organization <br />City of Santa Ana <br />Attn: Clerk of the City Council <br />20 Civic Center Plaza (M-30) <br />Santa Ana CA 92702-1988 <br />Job Description <br />For which the insured has agreed by <br />written contract executed prior to loss <br />to furnish this waiver. The premium <br />charge is 2°s of policy standard premium <br />at final audit. <br />Additional Premium % <br />We have the right to recover our payments from any- <br />one liable for an injury- covered by this policy. We <br />will not enforce our right against the person or <br />organization named in the Schedule. (This agreement <br />applies only to the extent that you perform work <br />under a written contract that requires you to obtain <br />this agreement from us,) <br />You must maintain payroll records accurately segre- <br />gating the remuneration of your employees while en- <br />gaged in the work described in the Schedule. <br />The additional premium for this endorsement shall be <br />the percentage, as shown in the Schedule applicable <br />to this endorsement, of the California workers' <br />compensation premium otherwise due on such <br />remuneration. <br />ftmm,ei ep? <br />Authorized Representative <br />WC040306