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I accept the coverage(s) as proposed above on behalf of City of Santa Ana and authorize American Specialty <br />to bind the following coverage(s): <br />© Commercial General Liability — $7,776, <br />Federal Terrorism Risk Insurance Act Premium — $285. <br />Purchasing Group Membership Fee — $100. <br />Please set billing up as: ❑ Agency Bill _R 0 Direct Bill (please choose one <br />Invoicing Contact: A- <br />E-Mail Address: S L a rw1 -Ar al ( , <br />�J <br />You agree to notify us of any change to this e-mail address. <br />If you have any questions, please contact your American Specialty Client Service Representative, <br />Jordan <br />Dawes, Client Services Rep. <br />In order to provide the Insured with more expeditious service we will be sending you the Insured's Policy(ies) <br />electronically in PDF format, unless we hear from you to the contrary. <br />Signature: StGN,MVW <br />Printed Name; FBI?l 6 ri Ne P_I D C C <br />Title: <br />Date: -l't [1Rr III <br />Note: American Specialty Insurance & Risk Services, Inc. has no affiliation with North American <br />Specialty Insurance Company. <br />©American Specialty Insurance & Risk Services, Inc. dba A.S.I.RS.I. Insurance Agency; American Specialty <br />Insurance & Risk Services Agency; and, A S Insurance & Risk Services Agency (9/11/2019) <br />