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TRAVELERS J' WORKERS COMPENSATION <br />AND <br />ONE :OWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD, CT 061113 <br />ENDORSEMENT WC 99 03 76 ( A) — 001 <br />POLICYNUMBER: (XJUB-329OT63-2-13) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />ENDORSEMENT - CALIFORNIA <br />(BLANKET WAIVER) <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not <br />enforce our right against the person or organization named in the Schedule. <br />The additional premium for this endorsement shall be 03.00 % of the California workers' compensation pre- <br />mium. <br />Schedule <br />Person or Org&nization <br />ANY PERSON OR ORGANIZATION FOR <br />WHICH THE INSURED HAS AGREED <br />BY WRITTEN CONTRACT EXECUTED <br />PRIOR TO LOSS TO FURNISH THIS <br />WAIVER. <br />City of Santa Ana; its appointed and elected officers, officials. and employees <br />Job Description <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise <br />stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of <br />the policy.) <br />Endorsement Effective <br />Insured JLee Engineering. Inc. <br />Insurance Company <br />Policy No. UB3290T632 <br />Endorsement No. <br />Premium <br />Countersigned by Leslie Pancoast <br />DATE OF ISSUE: 09-25-14 ST ASSIGN: Page 1 of 1 <br />