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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 79 <br />(Ed. 01-13) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br />- CALIFORNIA <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will <br />not enforce our right against the person or organization named in the Schedule. (This agreement applies <br />only to the extent that you perform work under a written contract that requires you to obtain this agreement <br />from us.) <br />You must maintain payroll records accurately segregating the remuneration of your employees while en- <br />gaged in the work described in the Schedule. <br />The additional premium for this endorsement is $ <br />Schedule <br />Person or Organization <br />The City of Santa Ana, its officers, employees, and agents <br />20 Civic Center Plaza, Santa Ana, CA 92791 <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless <br />otherwise stated. <br />(The Information below is required only when this endorsement is issued subsequent to preparation of <br />the policy.) <br />Endorsement Effective 11/1512016 <br />Policy Effective 11/1512016 <br />State California <br />Policy No. XWS56380327 <br />Insured HdL Coren and Cone <br />Endorsement No. 0009 <br />Premium $250.00 <br />Insurance Company Ohio Security Insurance Company <br />Countersigned by <br />WC 99 06 79 <br />(Ed. 01-13) <br />Q 2013 Liberty Mutual Insurancz <br />Includes copyrighted matanal of VVCIRB.with its permission. <br />21UG1;?o l7 <br />�✓ A P P R 0 1 E� <br />19291 Illy �E <br />