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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <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 />Schedule <br />Person or Organization Job Description <br />City of Santa Ana 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 dale issued unless otherwise stated. <br />(The Information belowis required onlywhen this endorsement Is Issued subsequent to preparation of the pollcy.) <br />Endorsement Effective 10/31/2013 Policy No.PSW0001252 <br />Insured Insurance Company <br />Joseph C. Truxaw and Associates, Inc. RLI Insurance Company <br />Countersigned By <br />Endorsement No. <br />0199II by the Workers' Compensation Insurance Rating Bureau of California. All rights reser <br />PROT 'AS TO FORM <br />LISA E. STORCK <br />CMT No.: 20145654 (AVC) xeeey Tran 5/1312014 10:43:37 AN (P0T1 Page s of 5 Assistant City Attorney <br />() <br />