Laserfiche WebLink
S �?,` }({ <br />1/A CC)N51.1l:TIiVG. InIC RI=CA A/�4/15 AGIR S! T6D IIEVIE1MEp El`r. ! !' FUA(IC:E IFkE(l IA (6 OF 9) <br />TRAVELERS WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76(00) — 001 <br />POLICY NUMBER: ue7r,6sysas <br />OTHENS <br />ENDORSEMENT <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: All. operations as pertains to named <br />20 Civic Center. Plaza insured, <br />Santa Ana CA 92702 The City of Santa Ana, its mff.i.cers, <br />einployeea, agents., volunteers and <br />ropresentatives <br />DATE OF ISSUE: 2/27/201.5 ST ASSIGN: CA <br />017106 <br />