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<br />AUI-II-OZ 01 :IOp. From-ROBERT F DRIVER '""' <br /> <br />+141-Z51-1663 ,..,,-Z75 P OOI/DOZ F-BI4 <br />A--W02- /05-61 <br /> <br />VENDORS/CONTRACTORS GENERAL LIABILITY REOUEST TO BIND COVERAGE <br /> <br />Contractors Progrtlm - Complm top secUOII and rerum to Driver AIliIznt to Bind. <br />Attention: Monique Nal/Qrro, Accou"t Administrator (949) 151-1663 <br /> <br />(COVERAGE NOT IN FORCE UNm BINDER RECEIVED FROM COMPANY) <br /> <br />Date: _~_L!~/~ <br /> <br />Public Entity: City of San~a Ana <br /> <br />Fax: (714) 647-5311 <br /> <br />CO.Dtact: Rosa Florea <br /> <br />V cndor 1 COntnlctor: <br /> <br />Ach1evemen~ Insti~ute of Sc1entifi~ Studies <br /> <br />Vendor 1 Conlr3c'lor Mailing Addr~: <br /> <br />1621 Bullard Lane <br /> <br />Santa Ana, CA 92705 <br /> <br />Description of ConlIact: <br /> <br />Coasult.ing <br /> <br />COntnlct Value: <br /> <br />$2,500.00 <br /> <br />Scope or Work.: CODsul~1ng High School Students <br /> <br />TermofContrllCl: From 8/14/02 To; 12/31/02 Hazard: <br /> <br />I <br /> <br />Rate: <br /> <br />$SOO.oo <br /> <br />Please biOO thc above account effeclive ...!.-!-.l!!_1 ~ <br /> <br />Total Policy premiu..: <br />State Tax (3%): <br />StampiDg Fee (.25%): <br />Certif"lUte J1ee: <br />Total Amouot; <br /> <br />5 500.00 <br />5 l~.OO <br />S 1.25 <br />5 $SO <br />5 566.25 <br /> <br />--.----...- <br />BINDER ACKNOWLEDGEMENT <br /> <br />Date: ~flJQ' <br /> <br />Contnlclor is Bound Effcclive: ~ I 1<11 (J.,).--ColonyInsuranceCornpany. <br />Masler Policy Number: CP-3073022 <br /> <br /> <br />COVERAGE IN FORCE FOR NAMED CONTRACT ONL Yo _ ~ <br />Publi~tYisN~as~~:iO~I;nS~ ~~!3:L. <br /> <br />~Jeo-- " =' ~ T If' C/ <br /> <br />Authorized Rcprcsenlative Driver Allial1l Ph: (949) 756-0271 <br />R.E. Chaix &: A...ociates Insur8lU:e Brokers. Inc. P.O. Hox 6450 Fax: (949) 251-1663 <br />LicCDSC 110726213 Newport Beach. CA 92660 <br />Liccuse #OC36861 <br /> <br />Sample of Policy is 00 file with the Public EDOty aDd caD be provided upoo requesl. <br /> <br />SllS'....17'.........""'!lIIt.lIll_"'" <br /> <br />u61T1I02 <br />