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AW <br />TRAVELERS WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76(00) — 001 <br />POLICY NUMBER: UB6771Y518 <br />I'LS <br />CIO, <br />ENDORSEMENT CALIFORNIA <br />(BLANKET WAIVER) <br />We have the right to recover our payments from anyone liable for an injury covered by this <br />policy. We will not enforce our right against the person or organization named in the Schedule. <br />You must maintain payroll records accurately segregating the remuneration of your <br />employees while engaged in the work described in the Schedule. <br />The additional premium for this endorsement shall be 3.00 % of the California workers' <br />compensation premium otherwise due on such remuneration. <br />Schedule <br />Person or Organization Job Description <br />City of Santa Ana Re: A-2015-163 OnCall & A-2015-237 <br />20 Civic Center Plaza OnCall -- City of Santa Ana and their <br />Santa Ana CA 92701 officers, agents and employees <br />DATE OF ISSUE: 1/27/2016 <br />ST ASSIGN: CA <br />REVIEWED BY: <br />RJNKE". HDREEM (F'G 91.)F 4�1) <br />