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(Ed.04-84) <br />ITRIUVIA *AQ 90111111 fa Urefla dK41 Iq <br />We have the right to recover our payments frorri anyone liaNe for an injury covered by this policy. We will riot enforce <br />our right against the person or organization earned in the Schedule, (This agreement applies only to the extent that you <br />perform work under a written contract that requires YOU to obtain this agreernent from US) <br />You rnUSt maintain payroll records accurately segregating in(,. remuneration of your employees while engaged in the <br />work described in the Schedule, <br />"The additional premium for this endorsement shall be 5,00% of the California workers' con-ilpensation premium <br />otherwise due on such remuneration. <br />Person or Organization <br />City of Santa Aria Community <br />City of Santa Ana Community D(":veloprnent Agency <br />Attri: Terri Eggers <br />333 W. Ocean Blvd., Long Beach, CA 92701 <br />Contract Ii 20'12-0501 City of Santa Ana, its officers, <br />agents, employees and volunteers <br />All Operations of the Narned Insured <br />This endorSeMent changes the policy to which it is attached sand is effective on the date tissued unless otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement Effective 2016-02-01 Policy No. Endorsement No. 7 <br />Insured WC201600005078 <br />Interval House <br />IrMlra?)W Company Countersigned By <br />New York Marine and General Insurance <br />Company 128746 <br />WC 0,4 03 06 <br />(Ed. 04-84) <br />U1998 bythe Workers' Cornpensation Insurance Rating Buraau cl Caffornia. Y\4 n4its reserved Z� <br />Q <br />