Laserfiche WebLink
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br />WC 04 03 06 (Ed. 4-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - <br />CALIFORNIA <br />This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a <br />different date is indicated below. <br />(The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy.) <br />This endorsement, effective on 4!1!2012 at 12:01 A.M. standard time, forms a part of <br />(DATE) <br />Policy No. 72 WE DQ2237 of the HARTFORD CASUALTY INSURANCE COMPANY <br />(NAME OF INSURANCE COMPANY) <br />issued to BEST, BEST & KRIEGER LLP <br />Endorsement No <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 1.00 % of the California workers' compensation premium <br />otherwise due on such remuneration. <br />Schedule <br />Person or Organization <br />City of Santa Ana 20 Civic Center Plaza, Santa Ana, CA <br />92701 <br />WC 252 (4-84) <br />WC 04 03 06 (ED. 4-84) <br />Attachment Code: D466017 <br />Certiflcate ID: 11767171 <br />Job Description <br />See Attached Certificate and Description of Operations <br />Page 1 of 1 <br />