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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA <br />WC 04 08 06 <br />(Ed. 4-84) <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 />Schedule <br />Person or Organization Job Description <br />City of Santa Ana, its officers and employees Jobs performed for any person or organization that you <br />have agreed with in a written contract to provide this <br />agreement. <br />This endorsement changes the pollcy to which It Is attached end 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 poll eyj <br />Endorsement Effective 2/11/2017 <br />Insured <br />D, Woolley & Assoclates, Inc.; <br />Harbinger Analytics Group <br />Policy No.PSW0001324 <br />Insurance Company <br />RLI Insurance Company <br />Countersigned By <br />Endcrsement No. <br />01998 by tho Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />36690201 1 2/17-1e cL/AUM/nxcSss/WC/PL I (AVC) Betty Tran 1 9/14/2019 9,3o:4e AM (PDT) I edge S of s <br />REVIEWED BY---- EUNICE HEREDIA (P(6 0F ) <br />