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7615 MAR 214 AJI IC; 5 I <br />°2206 7 - /q7 <br />,9/Ylz,-A) P nd, 9 -.v 7- <br />4 - 20141- 06V-0I <br />CITY OF qAH C ". „ „, <br />CLIP 11� �� .l,,�CfTY OF SANTA ANA <br />OFFICE OF THE CITY ATTORNEY <br />Certificate of Liability Insurance <br />Checklist for Contractor Policies <br />Name of Contractor: 7h/c am p>w GROUP, T NC <br />Date Certificate of Liability Insurance Submitted: <br />Permit No. Issued: <br />Steps: (a) Obtain Copy of (Current) Contract; (b) Identify Insurance Paragraph in Contract; <br />(c) Review Insurance Requirements Stated in the Contract and Compare with the Certificate of <br />Insurance Submitted for Approval; and (d) Check -off Each Item Below During Your Review of <br />the Submitted Certificate of Insurance: <br />[� 1. Name and Address of a Producer 7. Policy Number and Check to Verify <br />Insurance is Effective During Project Date <br />[vj' 2. Name and/or Telephone Number for or Contract Term <br />Producer Contact <br />[✓r 3. Name and Address of Contractor <br />[L�- 4. Name of the Insurance Company ies <br />[� 5. Boxes Checked Identifying the Type of <br />Coverage <br />[� 6. Additional Insured Box May be Checked <br />and Separate Additional Insured <br />Endorsement Form Must Be Attached (make <br />sure the endorsement lists the insurance <br />policy #) and Verify Primary Language on <br />Acceptable Additional Insured Endorsement <br />[-]' 8. Correct Coverage Dollar Amounts Listed <br />[ ] 9. Project Description by Number or Location <br />A'- (if applicable) <br />[L]— 10. Name of City and Address <br />[� 11. Insurer's Signature Required <br />(not the contractor's signature) <br />[ ]� 12. To Ap rp ove, Write "Reviewed by [sign <br />,your name]” on Every Page of the <br />�Iydl2oh Endor Certificate <br />ment Insurance <br />and Writ he N <br />e umber of <br />Pages (ex. 1/4 or 4/4) <br />Contact the City Attorney's Office if you have any questions — Lisa Storck x 5207 <br />