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Workers' Compensation and Employers' Liability Insurance Policy <br />Waiver of Our Right to Recover From Others Endorsement - California <br />WC 04 03 06 <br />If the following information is not complete, refer to the appropriate Schedule attached to the policy. <br />Insured: CiviISource, Inc. <br />Producer: Dealey, Renton & Associates <br />Schedule <br />Person or Organization <br />City of Santa Ana <br />20 Civic Center Plaza <br />Santa Ana CA 92701 <br />Additional Premium % <br />We have the right to recover our payments from any- <br />one liable for an injury- covered by this policy. We <br />will not enforce our right against the person or <br />organization named in the Schedule. (This agreement <br />applies only to the extent that you perform work <br />under a written contract that requires you to obtain <br />this agreement from us.) <br />Authorized Representative <br />WC040306 <br />Policy Number 72WEGZQ4447 <br />Effective Date 7 / 6 / 2 016 <br />Job Description <br />Re: A-2015-163 OnCall & A-2015-237 <br />OnCall -- City of Santa Ana and their <br />officers, agents and employees <br />You must maintain payroll records accurately segre- <br />gating the remuneration of your employees while en- <br />gaged in the work described in the Schedule. <br />The additional premium for this endorsement shall be <br />the percentage, as shown in the Schedule applicable <br />to this endorsement, of the California workers' <br />compensation premium otherwise due on such <br />remuneration. <br />RtIUCl �, i lM.0FEREDA (� G ..0 <br />d a. <br />f <br />