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WORI¢RV COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY NAC 04 0306 <br />(Ed. +44) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- <br />CAUFORNIA <br />We tows the right to recover our payments from anyone Mable for an injury covered by this policy. We will not <br />enforce our right against the person or organization neared in the Schedule. (This agreement applies only to the <br />exterA that 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 <br />the work described in the Schedule. <br />The additional premium for this endorsement shall be 0.00 % of the California workers' compensation pre- <br />mium otherwise due on such remuneration. <br />Parson or Organization <br />ALL PERSONS AND/OR <br />ORGANIZATIONS THAT <br />ARE REQUIRED BY <br />WRITTEN CONTRACT OR <br />AGREEMENT WITH THE <br />INSURED, EXECUTED <br />PRIOR TO THE <br />ACCIDENT OR LOSS, <br />THAT WAIVER OF <br />SUBROGATION BE <br />PROVIDED UNDER THIS <br />POLICY FOR WORK <br />PERFORMED BY YOU FOR <br />THAT PERSON AND/OR <br />ORGANIZATION <br />Schedule <br />Job Doscrlplion <br />ALL CA OPERATION <br />City of Santa Ana, its officers, employees, agents, <br />volunteers and representatives <br />All American Asphalt <br />Policy #WC5932057-02 <br />8/1/15 <br />Project #15-6839 /RE: Local Street Slurry Seal 2014-15 <br />Zurich American Ine. Co. <br />M 252 fel <br />WC 04 03 06 (Ed. 4A4) Pepe 1 of 1 3970 <br />