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C)VII. SOURCE AGR # TBD <br />REVIEWED BY .,. EUNICE HEREDIA (PC 6 OF 5) <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76(00)— 001 <br />POLICY NUMBER: ua6771Ys18 <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: City Engineering Services -- City <br />20 Civic Center Plaza of Santa Ana and their officers, agents <br />Santa Ana CA 92701 and employees <br />DATE OF ISSUE:7/17/2015 ST ASSIGN: CA <br />017106 <br />