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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA <br />WCO40308 <br />We have the right to recover our payments from anyone liable for on 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 3 % of the California workers' compensation premium <br />otherwise due on such remuneration. <br />Person cvOrganization <br />City of Santa Ana <br />its officers and employees <br />Schedule <br />Job Description <br />Jobs performed for any person or organization that you <br />have agreed with ina written contract to provide this <br />agreement. <br />This endorsement changes the policy to which nisattached and is effective on the date issued unless otherwise stated. <br />(The Information below Is required only when this endorsement Is Issued subsequent to preparation of the policy.) <br />Endorsement Effective 7/1/2016 Pol|cymuPSWO0O1494 <br />Insured Insurance Company <br />Albert Grover aAssociates, Inc. RL| Insurance Company <br />Countersigned By <br />Endorsement No. <br />' <br />��mm/ym^wvmu� Compensation Insurance Rating Bureau m California. All rights <br />HEREDA <br />REVIEWED BYi <br />30 n`m3 / 7 1^-n 9 .zoa/ ,en` <br />