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I <br /> CITY OF SA1VTA ANA <br /> Risk Management a division of Human Resources <br /> Managing Risk through Awareness and Action k' <br /> AFFIDAVIT OF EXEMPTION FOR.AUTOMOBILE LIABILITY INSURANCE <br /> 1, V �eQYI, T}(QE(�,1ve. �YI feofvr C"Representative"), attest that I am an authorized <br /> Marne and Title N Vendar Representative) <br /> representative of I ht L'.66t'►'1944atl rni iu ("Company"),and <br /> (Consultanvcornpnn Nnne) <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 - N h <br /> ("Agreement")to provide fly 5 I�` �r fia ("Services"): i <br /> Services to be provided tinder agreement/eoninc) # <br /> During the course and scope of Company's agreement with the City ofSanta Ana, i <br /> Company employees,consultants,representatives,and agents will not use and/or drive <br /> any Company owned/rented/lcased/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 niimiinunl 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 /> Signature Bate <br /> ................................... . <br /> Print Name <br /> Contact Infornmtion,i.e.,Tele phone Number <br /> ! and/or Email Address <br /> I <br /> �I <br /> i <br /> Affidavit of Exemption for Automobile Liability Insurance 11.12.2024 <br />