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CITY OF SANTA ANA <br /> Risk Management a division of Human Resources z"'✓ <br /> Managing Risk through Awareness and Action ' <br /> AFFIDAVIT OF EXEMPTION FOR AUTOMOBILE LIABILITY INSURANCE <br /> PIr it'd?/""("Representative"),attest that I am an authorized <br /> ante and Title of Vendor epresentative) <br /> t I <br /> representative off ( r ("Company"), and <br /> (C nsul e t/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 N <br /> /& <br /> ("Agreement")to provide 11 VeS fI M �n l i tli 1 y r b5� c. y?G. �ir*Services-): <br /> (SeplVices to be provided under agreement/contract) IIJ <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 /> documcnt 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 /> Signature Date <br /> ze46W <br /> pelTa <br /> Print Na <br /> 1 <br /> Title <br /> :214 qqTlatl <br /> Contact Information,i.e.,Telephone Number and/or Email Address <br /> Affidavit of Exemption for Automobile Liability Insurance 11.12.2024 <br />