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CITY OF SANTA ANA <br />7015 FF'O 24 AM 9: 114 <br />CITY Of-' SAWIA ANA <br />CLERK O <br />OFFICE OF THE CITY ATTORNEY <br />Cu99G;Cr 1nrSu.rt a•Ke- <br />Certificate of Liability Insurance ro"s ea rltL R06_ <br />Checklist for Contractor Policies c`witFo <br />A -2012 -080 <br />Name of Contractor: 3�GN4Tu2b /gGf/�✓bL0(j/ �2®�' vemvo,�, <br />Date Certificate of Liability Insurance Submitted: _ 1 1"l `✓ V16L N4 1 <br />Permit No. Issued: <br />Steps: (a) Obtain Copy of (Current) Contract; (b) Identify Insurance Paragraph in Contract; <br />(c) Review Insurance Requirements Stated in the Contract and Compare with the Certificate of <br />Insurance Submitted for Approval; and (d) Check -off Each Item Below During Your Review of <br />the Submitted Certificate of Insurance: <br />[✓]� 1. Name and Address of a Producer <br />[✓r2. Name and/or Telephone Number for <br />Producer Contact <br />[-J'3. Name and Address of Contractor <br />[vy 4. Name of the Insurance Company(ies) <br />[� 5. Boxes Checked Identifying the Type of <br />Coverage <br />[A.]' 6. Additional Insured. Box May be Checked <br />and Separate Additional Insured <br />Endorsement Form Must Be Attached (make <br />sure the endorsement lists the insurance <br />policy #) and Verify Primary Language on <br />Acceptable Additional Insured Endorsement <br />7. Policy Number and Check to Verify <br />Insurance is Effective During Project Date <br />or Contract Term w r L L CI P, 5 <br />/ .2.41(0 <br />[ ] 8. Correct Coverage Doll Amounts Listed <br />elaloX or- Jr-,elo <br />[ ] 9. Project Description by Number or Location <br />(if applicable) 01A <br />[-]' 10. Name of City and Address <br />[✓] 11. Insurer's Signature Required <br />(not the contractor's signature) <br />[ �?'12. To Ap rp ove, Write "Reviewed by [sign <br />your name]" on Every Page of the <br />Certificate of Insurance and all <br />Endorsements and Write the Number of <br />Pages (ex. 1/4 or 4/4) <br />Contact the City Attorney's Office if you have any questions — Lisa Starck x 5207 <br />Ei✓ators�.ryr�(3 revious�{( "Olded <br />Gtv� c0�c1'�n��lv'i��u-4 Uh'�'M4e--P <br />Geg'd2�� <br />