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CITY OF SANTA ANA <br />OFFICE OF THE CITY ATTORNEY <br />erdicate of Liaability Insurance <br />Checklist for Consultant/Sub-recipient Policies <br />Name of Consultant/Sub-recipient: t\(cffl Ut l!l KS <br />Date Certificate of Liability Insurance Submitted: 61-2- } I ZC i Qi <br />Steps: (a) Obtain Copy of (Current) Contract; (b) Identify Insurance Paragraph in Contract; <br />(c) Review Insurance Requirements Stated in the Contract and Compare with the Certificate of <br />Insurance Submitted for Approval; and (d) Check -off Each Item Below During Your Review of <br />the Submitted Certificate of Insurance: <br />1. Name and Address of a Producer V] 7. Policy Number and Check to Verify <br />Insurance is Effective During Project Date <br />2. Name and/or Telephone Number for or Contract Term <br />Producer Contact <br />[ 3. Name and Address of Consultant/Sub <br />[�J 4. Name of the Insurance Company(ies) <br />[/] 5. Boxes Checked Identifying the Type of <br />Coverage <br />[/] 6. Additional Insured Box May be Checked <br />and Separate Additional Insured <br />Endorsement Form Must Be Attached <br />(make sure the endorsement lists the <br />insurance policy #) and Verify Primary <br />Language on Acceptable Additional Insured <br />Endorsement <br />8. Correct Coverage Dollar Amounts Listed <br />Y J 9. Professional Liability Insurance Listed (if <br />/// architect, engineer, attorney or accountant) <br />[� 10. Project Description by Number or Location <br />(if applicable) <br />A 11. Name of City and Address <br />12. Insurer's Signature Required <br />(not the consultant's signature) <br />[� 13. To Approve, Write "Reviewed by [sign <br />your name]" on Every Page of Certificate <br />of Insurance and All Endorsements and <br />Write the Number of Pages (ex. 1/4 or 4/4) <br />Contact the City Attorney's Office if you have any questions — Lisa Storck x5207. <br />