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ALBERT GROVER & ASSOCIATES RFCA 10/21/15 PROJ 16 6861 REVIEWED BY: EUNICE HEREDIA (PG 3 OF 3) <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />(Ed. 4 -84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce <br />our right against the person or organization named in the Schedule. (This agreement applies only to the extent that <br />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 the <br />work described in the Schedule. <br />The additional premium for this endorsement shall be 2 % of the California workers' compensation premium <br />otherwise due on such remuneration. <br />«a1"Mmr <br />Person or Organization Job Description <br />City of Santa Ana Jobs performed for any person or organization that you <br />its officers, employees, and representatives have agreed with in a written contract to provide this <br />agreement. <br />This endorsement changes the policy to which It is attached and is effective on the date Issued unless otherwise stated. <br />(The information be low is required only when this endorsement Is Issued subsequent to preparation of the pol Icy.) <br />Endorsement Effective 7 /1/2015 PolicyNo.PSW0001494 <br />Insured Insurance Company <br />Albert Grover& Associates, Inc. RLI Insurance Company <br />Countersigned By <br />Endorsement No. <br />@1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />ss 1 1,- _crss/ .,mm ai ,'.o 1 1 / u = _,r_ _ I m, a ,x x <br />