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CITY OF SANTA ANA <br /> Risk Management a division of Human Resources <br /> Managing Risk through Awareness and Action 2 <br /> AFFIDAVIT OF EXEMPTION FOR AUTOMOBILE LIABILITY INSURANCE <br /> ("Representative"),attest that I am an authorized <br /> (Name an Title of Vendor Repr Vtive) ��'� <br /> representativ f �� ` �Z7� ("Company„),and <br /> (Consul tant/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 LL <br /> ("Agreement")to provide ("Services"): <br /> (Services to be provided under agreement/ontract <br /> During the course and scope of Company's agreement with the City of Santa Ana, I 1 <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 /> a <br /> Signature Date <br /> l <br /> i <br /> Print Name <br /> Cdo j <br /> Title <br /> 0/ � ) 7- 7 �z4 zz <br /> �- Z5, �) <br /> Contact formation,i.e.,'Telephone Num er and/or Email Address <br /> Affidavit of Exemption for Automobile Liabilitv Insurance 11.12?rn4 <br />