Laserfiche WebLink
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;PENC0 Engineering, Inc. <br />Producer: Dealey, Renton & Associates <br />Schedule <br />Person or Organization <br />City of Santa Ana <br />20 Civic Center Plaza -Ross Annex (M-36) <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 car 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 ❑ written contract that requires you to obtain <br />this agreement from tis,) <br />Iljaru;,.. J'hrn P <br />Authorized RelimsentAiN e <br />wcoaoaee <br />Policy Number WZP81028890 <br />Effective Date 11/20/2015 <br />Job Description <br />Any person or organization for which the <br />Insured has completed a written <br />agreement to provide this waiver <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 clue on such <br />remuneration. <br />RFVIEVVED BY//j —A - EUNICE HEREDIA lPG 7 OF Iffi <br />