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CITY OF SANTA ANA <br /> Risk Management a division of Human Resources K<< <br /> Managing Risk through Awareness and Action <br /> AFFIDAVIT OF EXEMPTION FOR AUTOMOBILE LIABILITY INSURANCE <br /> I, 04LY�,C�CA r l Y1��t ►�_("Representative"),attest that I am an authorized <br /> (Name and Title of Vendor Representative) <br /> representative of _n � E tY ("Company"), and <br /> (Consultant/Company Name <br /> possess the authority to legally bind Company. <br /> In my capacity as Representative of Company, I represent and confirm the following, as relates to the <br /> agreement between Company and City of Santa Ana, agreement number <br /> ("Agreement")to provide LC• :: ("Services"): <br /> {services to be provide under agreement/eontraet) <br /> During the course and scope of Company's agreement with the City of Santa Ana, <br /> Company employees, consultants, representatives, and agents will not use and/or drive <br /> any Company owned/rented/leased/borrowed vehicles to perform Services to,for,or on <br /> behalf of City of Santa Ana. <br /> If at any time it is found that Company is not adhering to any and/or all of the statements in this <br /> document and does not maintain the minimum automobile liability insurance coverage as <br /> required in the Agreement, it will be considered a breach of Agreement rendering the Agreement <br /> null and void and Company will be fully liable for any and all damages. <br /> ig ature Date <br /> t f <br /> Ct 1 C- <br /> Print Name <br /> Title <br /> \A P n C I n nez -n hi a cj"'1 Cc)", <br /> Contact Information,i.e.,Telephone Number and/or Email Address <br /> Affidavit of Exemption for Automobile Liability Insurance 11,12.2024 <br />