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CITY OF SANTA ANA <br /> Risk Management a division of Human Resources <br /> Managing Risk through Awareness and Action A° <br /> AFFIDAVIT OF EXEMPTION FOR AUTOMOBILE LIABILITY INSURANCE <br /> I, 1l IXhi[ —k" �QLpaA ("Representative"),attest that I am an authorized <br /> (Name and Titl of Vendor Representative) <br /> representative of Qi ("Company"), and <br /> �T(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 /> ("Agreement")to provide L14 A- way q I ecyV A"w ("Services"): <br /> (Services to a pro%lde&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 /> §jj--14a4 ot ;Lo^ ---- MA11111- <br /> Signature W <br /> Print V'amc <br /> I-itlr <br /> Contact Information,i.e.,-Telephone Number and/or E m-07rdNss <br /> Affidavit of Exemption for Automobile Liability Insurance 11.12.2024 <br />