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CITY OF SANTA ANA <br />Risk Management a division of Human Resources <br />Managing Risk through Awareness and Action <br />AFFIDAVIT OF EXEMPTION FOR AUTOMOBILE LIABILITY INSURANCE <br />Gmpsn/Dbnqpt <br />I, ________________________________________ (“Representative”), attest that I am an authorized <br />(Name and Title of Vendor Representative) <br />GmpsN/Dbnqpt <br />representative of __________________________________________________ (“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 />BevmuBsuDmbttft <br />(“Agreement”) to provide ____________________________________________________ (“Services”): <br />(Services to be provided under agreement/contract) <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 />201503137 <br />__________________________________________________________ ___________________ <br />Signature Date <br />GmpsN/Dbnqpt <br />______________________________________________________________________________ <br />Print Name <br />BsuJotusvdups <br />______________________________________________________________________________ <br />Title <br />)825*91:.59:40tjqboeqbjourvffoAhnbjm/dpn <br />______________________________________________________________________________ <br />Contact Information, i.e., Telephone Number and/or Email Address <br />Affidavit of Exemption for Automobile Liability Insurance 11.12.2024 <br />