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<br />. <br /> <br />f'l -100 ~- 01 ~ <br /> <br />VENDORS/CONTRACTORS GENERAL LIABILITY REOUEST TO BIND COVERAGE <br /> <br />Contractors Program - Complete top section and return to R. F. Driver to Bind. <br />Attention: Monique Navarro, Account Administrator <br /> <br />(COVERAGE NOT IN FORCE UNTIL BINDER RECEIVED FROM COMPANY) <br /> <br />Date: ----!LI--19.! ~ <br /> <br />Public Entity: <br /> <br />Santa Ana <br /> <br />Fax: (714) 647-5311 <br /> <br />Contact: Rosa Flores <br /> <br />Vendor / Contractor: <br /> <br />Virginia G. Mayne <br />1601 E. Avalon Avenue <br /> <br />Vendor / Contractor Mailing Address: <br /> <br />Santa Ana, CA 92705 <br /> <br />Description of Contract: <br /> <br />Consulting at Work Cent~ontractValue: <br /> <br />Not to exceed $10,000 <br /> <br />Scope of Work: <br /> <br />Consulting at City I S Work Center for job preparedness <br /> <br />Term of Contract: From 6/01/02 To: 6/30/03 Hazard: <br /> <br />I <br /> <br />Rate: <br /> <br />$300.00 <br /> <br />Please bind the above account effective ~/ ~/ ~ <br /> <br />Total Policy Premium: $ <br />$300.00 <br />State Tax (3%): $ 9.00 <br />Stamping Fee (.25%): $ 0.7r:) <br />Certificate Fee: $ $50 <br />Total Amount: $ 359.ilS <br /> <br />BINDER ACKNOWLEDGEMENT <br /> <br />Date:lI OIl Qa <br /> <br />Contractor is Bound Effective: ~ 0 / / 0 J-vu1crum Insurance Company. <br />Master Policy Number: CP.1002566 <br /> <br /> <br />D AS 1'0 PORM <br /> <br />CRIST! E LEE SHAW <br />Deputy City Attorney <br />COVERAGE IN FORCE FOR NAMED CONTRACT ONLY. . . /U <br /> <br />pUbQ:;~a~da~~1ed: ~~cr <br /> <br /> <br />Authorized Representative Robert F. Driver Ph: (949) 756-0271 <br />R.E. Chaix & Associates Insurance Brokers, Inc. P.O. Box 6450 Fax: (949) 756.2713 <br />License #0726213 Newport Beach, CA 92660 <br />License #OC36861 <br /> <br />Sample of Polley is on file with the Public Entity and can be provided upon request. <br /> <br />S~i.ILy/vmdQIl1Vbin.~uestrrm <br /> <br />1/3111002 <br />