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HomeMy WebLinkAboutGREYHOUND LINES, INC. (15) A-2023-090C MAYOR f f A CITY MANAGER Valerie Amezcua a I r :� f�� .. 'aa* Alvaro Nunez MAYOR PRO TEM It 2�26 11:. ,,. CITY ATTORNEY David Penaloza J Sonia R.Carvalho COUNCILMEMBERS CITY CLERK Phil Bacerra " Jennifer L.Hall Johnathan Ryan Hernandez '� ' Jessie Lopez Thai Viet Phan BenjaminVazquez CITY OF SANTA ANA M.Wit {pzy PUBLIC WORKS AGENCY N•0(97AD 20 Civic Center Plaza.P.O.Box 1988 Santa Ana,California 92702 —.santa-ana.ora May 14, 2026 Greyhound Lines,Inc. Attn: Real Estate P.O. Box 660362 Dallas, TX 72566 Re: Extension of License Agreement(A-2023-090)for Use of the Santa Ana Re;ional Transportation Center(SARTC) Facilities Pursuant to Section 13 ("Commencement Date of Agreement") of the above-referenced Agreement, entered into by Greyhound Lines, Inc. ("Licensee"), and the City of Santa Ana, dated May M, 2023, the time period of the Agreement is hereby extended for an additional one-year period through June 30,2027.Any insurance certificates are required to be extended and/or renewed to cover this extension. All other terms and conditions of the Agreement, including the Consent to Sub-License Agreement (#A-2023-090-01) dated February 29, 2024, remain unchanged and in full force and effect. Sincerely, _ fo Ro as, P.E. Acting Executive Director, Public Works Agency CITY OF S ANA ATTEST At-y`aro Nunez nnifer 11 '.� City Manager e i APPROVED AS TO FORM GREYHOUND LINES,INC. J(){I'/] Signed lay; KT e Nellesen By; Robert Kriedberg Assistant City Attorney Title: Head of Real Estate SANTA ANA CITY COUNCIL Valene Amezcua David Penaloza Thai Viet Phan Benjamin Vazquez Jessie Lopez Phil Bace a Johnathan Ryan Hernandez Mayor Mayor Pro Tern-Ward 6 Ward 1 Ward 2 Ward 3 Ward 4 Ward 5 amezcuaCa?san+aana.om doenalozaAsanla-ana,oro tohanfRwta-aua.oro lrvazauez0santa-ana.ero iessielooezfa7santa-ana.ora odacena(rilsanta-ana.om irvanhernande&gI4,nta-ana„grg AC 0®EP CERTIFICATE OF LIABILITY INSURANCE DAT / 4411 116 sl2026 YI oz5 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements. PRODUCER CONTACT ONE CT Nancy do Jeffery McGriff,a Marsh&McLennan Agency LLC Company PHONE 503-943-i3621 FAx 601-748-3878 5400 SW Meadows Road,Suite 240 AIc No Ext: A!C No): Lake Oswego,OR 97035 E-MAIL Nanc Jeffe ADDRESS: y ry@MarshMMA.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Bus Risk Retention Group 17324 1119URED INSURER B:The Insurance Company of the State of Pennsylvania 19429 NIX North America,Inc. Greyhound Lines,Inc. INSURER C:National Union Fire Insurance Company of Pittsburgh,PA 19445 PO Box 660632 INSURER D-AIU Insurance C Dallas,TX 75286-0362 Company� 19399 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:3YY6PLEK REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN$R TYPE OF INSURANCE POLICY EFF POLICY EXP - LTR NSD 1WD POLICY NUMBER MWDI)YY MMIDOMYYY LIMITS A X COMMERCIAL GENERAL LIABILITY GL-RRG-001023 01/01/2026 01/01/2027 EACH OCCURRENCE $ 10,000,000 - DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES Ea or $ 5,000,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 10,000.000 - GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 10,000,000 POLICY❑PE0. [X]LOC PRODUCTS-COMP/OPAGG $ 10,00C,000 OTHER: $ A AUTOMOBILE LIABILITY L-RRG-001023 01/01/2026 01101/2027 Ea a88INED SINGLE LIMIT 10,000,000 X ANY AUTO BODILY INJURY(Per person) $ - OWNED SCHEDULED BODILY INJURY Perawident AUTOS ONLY AUTOS ( ) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ B WORKERS COMPENSATION 062790879 AOS O4/01/2026 0410112027 X PER OTH- AND EMPLOYERS'LIABILITY YIN I STATUTE ER ANY PROPRIETORMARTNERIFXECUTIVE ❑ F.L.EACH ACCIDENT $ 3,000,000 OFHCERW EMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 3,000,000 If yes,describe under 3,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Auto Liability AL7281073(AOS) 04/01/2026 04101/2027 Combined Single Limit $ 10,000,000 D L7281072 MA) $ $ $ DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES {ACORD 101,Addlflonal Remarks Schedule,may be attached if more space is required) RE:Leased Location:The Depot at Santa Ana:1000 East Santa Ana Boulevard,Santa Ana,CA.City of Santa Ana,Its agents,officers,employees and volunteers are included as Additional Insured as respects the ongoing operations of the Named Insured with respect to General Liability coverage on a primary and non-contributry basis when required by written and signed contract per policies terms,conditions,limits and excluslosn. Waiver of Subrogation Is granted in favor of City of Santa Ana,Its agents,officers,employees and volunteers with respect to General Liability and Workers'Compensation coverage when required by written contract.30 day notice of cancellation in favor of certificate holder per policies terns and conditions. APPROVED CERTIFICATE HOLDER CANCELLATION By TT.Nguyemat� 9 am.n._�_.,..c*�'�n2l SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Santa Ana Attention: PWA Facilities AUTHORIZED REPRESENTATIVE 20 Civic Center PI,M11 + Santa Ana,CA 92701 Page 1 of ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD j TE '4� EVIDENCE OF PROPERTY INSURANCE 3YY5PLEK DA04/16/2O 6 Y} THIS EVIDENCE OF PROPERTY INSURANCE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ADDITIONAL INTEREST NAMED BELOW. THIS EVIDENCE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS EVIDENCE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE ADDITIONAL INTEREST. AGENCY PHONE 1: 503-943-6621 COMPANY McGriff,a Marsh&McLennan Agency LLC Company Lexington Insurance Co. 5400 SW Meadows Road,Suite 240 Lake Oswego,OR 97035 Nancy Jo Jeffery FAX c Nu: 501-748-3878 ADDRESS: Nancy,Jeffery@MarshMMA.com APPROVED CODE: SUB CODE: By Tu Tran Nguyen at 9;11 am,Apr 16,.2026 AGENCY CUSTOMER ID# INSURED LOAN NUMBER POLICY NUMBER RIX North America, Inc. 14627205 Greyhound Lines, Inc. PO Box 660632 EFFECTIVE DATE EXPIRATION DATE Dallas,TX 75266-0362 04/01/2026 tlg10112027 CONTINUEDUNTIL TERMINATED IF CHECKED THIS REPLACES PRIOR EVIDENCE DATED: PROPERTY INFORMATION LOCATIONIDESCRIPTION _ THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EVIDENCE OF PROPERTY INSURANCE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. COVERAGE INFORMATION PERILS INSURED 1 1 BASIC BROAD SPECIAL COVERAGE!PERILS!FORMS AMOUNT OF INSURANCE DEDUCTIBLE Building/Business Personal Property-Occurrence Limit $10,000,000 $1,000,000 Physical Damage-Maximum Any One Vehicle $700,000 2024 and 2025 Year-Units $250,000 2023 and Older $1,000,000 Physical Damage-Maximum Any one Occurrence $17,600,000 $1,000,000 REMARKS fincluding Special Conditions CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ADDITIONAL INTEREST NAME AND ADDRESS ADDITIONAL INSURED LENDER'S LOSS PAYABLE LOSS PAYEE MORTGAGEE LOAN# City of Santa Ana Attention: PWA Facilities AUTHORIZED REPRESENTATIVE 20 Civic Center PI,M11 Santa Ana,CA 92701 ACORD 27(2016103) O 1993-2015 ACORD CORPORATION.All rights reserved. Page 2 of 2 The ACORD name and logo are registered marks of ACORD ENDORSEMENT This endorsement, effective 12:01 A.M. 1/1/25 forms a part of Policy No. GL-RRG-001023 issued to GREYHOUND L I NES, I NC by BUS Risk Retention Group,Inc, PRIMARY COVERAGE FOR SPECIFIED PERSONS OR ORGANIZATIONS NAMED AS ADDITIONAL INSUREDS - ONGOING AND COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM The following paragraph is added to SECTION II - WHO IS AN INSURED and applies only to persons or organizations we have added to your policy as additional insureds by endorsement to comply with insurance requirements of written contracts relative to: a) the performance of your ongoing operations for the additional insureds; or b) "your work" performed for the additional insureds and included in the "products-completed operations hazard": This insurance is primary over any similar insurance available to any person or organization we have added to this policy as an additional insured. However, this insurance is primary over any other similar insurance only if the additional insured is designated as a named insured in the Declarations of the other similar insurance. We will not require contribution of limits from the other similar insurance if the insurance afforded by this endorsement is primary. This insurance is excess over any other valid and collectible insurance, whether primary, excess, contingent or on any other basis, if it is not primary as defined in the paragraph above. All other terms and conditions of the policy are the same. 90533 (3i06) Page 1 of 1 POLICY NUMBER:GL-RRG-001023 COMMERCIAL GENERAL LIABILITY CG20261219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): ANY PERSON OR ORGANIZATION WHOM YOU BECOME OBLIGATED TO INCLUDE AS AN ADDITIONAL INSURED AS A RESULT OF ANY CONTRACT OR AGREEMENT YOU HAVE ENTERED INTO. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section 11 — Who Is An Insured is amended to agreement, the insurance afforded to such include as an additional insured the person(s) or additional insured will not be broader than organization(s) shown in the Schedule, but only that which you are required by the contract with respect to liability for "bodily injury", or agreement to provide for such additional "property damage" or "personal and advertising insured. injury" caused, in whole or in part, by your acts B. With respect to the insurance afforded to these or omissions or the acts or omissions of those additional insureds, the following is added to acting on your behalf: Section III -- Limits Of Insurance: 1. In the performance of your ongoing If coverage provided to the additional insured is operations; or required by a contract or agreement, the most 2. In connection with your premises owned by we will pay on behalf of the additional.insured or rented to you. is the amount of insurance: However: 1. Required by the contract or agreement; or 1. The insurance afforded to such additional 2. Available under the applicable limits of insured only applies to the extent permitted insurance; by law; and whichever is less. 2. If coverage provided to the additional This endorsement shall not increase the insured is required by a contract or applicable limits of insurance. CG 20 26 12 19 Insurance Services Office, Inc., 2018 Page 1 of 1 ENDORSEMENT This endorsement, effective 12:01 A.M. 1/1/25 forms a part of Policy No. GL-RRG-001023 issued to GREYHOUND LINES, INC by BUS Risk Retention Group, Inc. NOTICE OF CANCELLATION_ [SCHEDULED NOTICE] This endorsement modifies insurance provided under the following. AUTO DEALERS COVERAGE FORM COMMERCIAL GENERAL LIABILITY COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM S .HEDJ.JI.E NOTICE WILL BE MAILED TO: TO THE ATTENTION OF: COMMON POLICY CONDITIONS, A. - Cancellation, 2. is amended to read: 2. We may cancel this policy by mailing or delivering to the first Named Insured written notice of cancellation at least: a, TH 1 RTY 3-0 * days before the effective date of cancellation if we cancel for nonpayment of premium; or b. TH I RTY 30 days before the effective date of cancellation if we cancel for any other reason in the event this policy is cancelled for any reason other than non-payment of premium, notice will be provided as set out in this endorsement to those Schedule entities. the notice period provided shall not be less than that required by applicable state law(s), 97285 (9/14) Includes copyrighted material of Insurance Services Office, Inc. with its permission. Page 1 of 1 COMMERCIAL AUTO CA 04 49 11 16 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY �- OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. A. The following is added to the Other Insurance B. The following is added to the Other Insurance Condition in the Business Auto Coverage Form Condition in the Auto Dealers Coverage Form and and the Other Insurance— Primary And Excess supersedes any provision to the contrary: Insurance Provisions in the Motor Carrier This Coverage Form's Covered Autos Liability Coverage Form and supersedes any provision to Coverage and General Liability Coverages are the contrary: primary to and will not seek contribution from any This Coverage Form's Covered Autos Liability other insurance available to an "insured" under Coverage is primary to and will not seek your policy provided that: contribution from any other insurance available to 1. Such "insured" is a Named Insured under such an insured under your policy provided that: other insurance; and 1. Such "insured" is a Named Insured under such 2. You have agreed in writing in a contract or other insurance; and agreement that this insurance would be 2. You have agreed in writing in a contract or primary and would not seek contribution from agreement that this insurance would be any other insurance available to such primary and would not seek contribution from "insured". any other insurance available to such "insured". CA 04 49 11 16 ©Insurance Services Office, Inc., 2016 Page 1 of 1 POLICY NUMBER COMMERCIAL AUTO AL-RRG-001023a CA 20 48 10 13 DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s)who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Greyhound Lines, Inc. Endorsement Effective Date: 01/01/25 SCHEDULE Name Of Person(s)Or Organlzation(s): Any person or organization that you agree in a "written contract requiring insurance" to include as an additional insured on this Coverage Part. "Written contract requiring insurance" means that part of any written contract or agreement under which you are required to include a person or organization as an additional insured on this Coverage Part, provided that the "bodily injury" and "property damage" occurs and the "personal injury" is caused by an offense committed: a.After the signing and execution of the contract or agreement by you; b.While that part of the contract or agreement is in effect; and c. Before the end of the policy period. Information required to complete this Schedule if not shown above will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured"for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section 11 — Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I — Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 10 13 ©Insurance Services Office, Inc., 2011 Page 1 of 1 ENDORSEMENT This endorsement, effective 12:01 A.M. 1/101/01/26 forms a part of Policy No. AL-RRG-001023 issued to Greyhound Lines,Inc. by BUS Risk Retention Group,Inc, INSURANCE PRIMARY AS TO CERTAIN ADDITIONAL. INSUREDS This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM Section IV - Business Auto Conditions, B., General Conditions, 5., Other Insurance, c., is amended by the addition of the following sentence: The insurance afforded under this policy to an additional insured will apply as primary insurance for such additional insured where so required under an agreement executed prior to the date of accident. We will not ask any insurer that has issued other insurance to such additional insured to contribute to the settlement of loss arising out of such accident. All other terms and conditions remain unchanged. 74445 (10/99) Page 1 of 1 POLICY NUMBER: AL-RRG-001023 COMMERCIAL AUTO CA 04 44 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Greyhound Lines,Inc. Endorsement Effective Gate: 01/01/25 SCHEDULE Name(s) Of Person(s) Or Organizationls): ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED IS REQUIRED TO PROVIDE A WAIVER. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization. CA 04 44 10 13 oinsurance Services Office, Inc., 2011 Page 1 of 1 ❑ POLICY NUMBER; GL-RRG-001023 COMMERCIAL GENERAL LIABILITY CG24041219 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s) Or Organization(s): AS REQUIRED BY WRITTEN CONTRACT OR AGREEMENT Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph B. Transfer Of Rights Of Recovery Against Others To Us of Section IV— Conditions: We waive any right of recovery against the person(s) or organizations) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 0 Insurance Services Office, Inc., 201 B Page 1 of 1 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The fallowing "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM forms a part of Policy No. 062790879 Issued to: FLIX NORTH AMERICA, INC By: THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA Premium We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us). You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be % of the California workers' compensation premium otherwise due on such remuneration. Schedule ANY PERSON OR ORGANISATION WITH WHOM YOU HAVE ENTERED INTO A CONTRACT REQUIRING YOU TO OBTAIN THIS WAIVER FROM US. THIS ENDORSEMENT DOES NOT APPLY TO BENEFITS OR DAMAGES PAID OR CLAIMED BECAUSE OF INJURY OCCURING BEFORE YOU ENTERED INTO SUCH A CONTRACT. Person or Organization Job Description WC 04 03 06 Countersigned by— — — — — - - — — — — — — — — - - - - - - - -- - - - - - - - (Ed. 04184) Authorized Representative