Laserfiche WebLink
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 <br />you perform work under a written contract that requires you to obtain this agreement frorn 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 <br />City of Santa Ana, <br />its officers and employees <br />JOSEPH C."T'RUXAW & ASSOCIATES: AGREEMENT # A-2014-100 <br />REVIEWED BY: k EUNICE HEREDIA <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 />This endorsement changes the poficytowhich it is attached and is effective on the date issued unless othenvise stated. <br />(The Information below is required only when this endorsement IS 1SSUed Subsequent to preparation of the policy.) <br />Endorsement Effective 10/31/2014 Policy No. PSWO001252 <br />Insured Insurance Company <br />Joseph C. Truxaw and Associates, Inc. RLI Insurance Company <br />Countersigned By <br />Endorsement No. <br />@1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved, <br />CERI z-o, ; 222 5 19 )1 (AVC� Be .y T­­ 11/6/.7014 7.51 1A AM (PST) Para,,, 5 of � <br />