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NOTICE OF COMPLIANCE <br />CITY <br />. "A ,AM I1111RI T I'III I IPi 1111AGE ,CND INCLUDE Ck I 111 1AGREEMENTTOT111IE CLERK CSC 111I➢C COUNCIL <br />Contractor Jorge B Melgoza <br />Name: <br />Project N-2022-027 <br />Number: <br />Project Agreement With Jorge Melgoza, DBA Ardent Ergonomics, To <br />Name: Provide Preventative Ergonomics Assessments <br />The Certificate of Insurance (COI) submitted indicates that the coverages are in <br />compliance with the insurance requirements. No further action is required at this time. <br />The compliant coverage(s) are: <br />TYPE OF INSURANCE <br />POLICY <br />EXPIRATION <br />COI DATE <br />FILE NAME <br />NUMBER <br />DATE <br />AUTOMOBILE LIABILITY <br />5837885DI555 <br />: 04/15/2023 <br />09/30/2022 <br />Melgoza.pdf <br />BUS CERT <br />GENERAL LIABILITY <br />90E3K8745 <br />10/15/2023 <br />10/10/2022 <br />2022 <br />MELGOZA.pdf <br />Affidavit of <br />Exemption for <br />WORKERS COMPENSATION AND <br />WAIVER <br />01/03/2024 <br />01/05/2023 <br />Workers <br />EMPLOYERS' LIABILITY <br />Compensation <br />Insurance <br />.............. <br />.............. <br />202 Lpdf <br />Thank you, <br />City of Santa Ana <br />Risk Management Division <br />in partnership with <br />CTrax Plus Services Team <br />1/9/2023 5:17 PM <br />