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201.5 fIAR _t] PH 1: 10 <br />CITY OF SAW AN/t <br />CLERK CITY OF SANTA ANA <br />/7_2012 -192, <br />09 - Z 0// <br />FIGRCE/r/�T <br />OFFICE OF THE CITY ATTORNEY <br />Certificate of Liability Insurance <br />Checklist for Contractor Policies <br />Name of Contractor: PA C! F1 C S ER V D c L--,S 170c� • 7 <br />Date Certificate of Liability Insurance Submitted: _02 /x/ 2 0 /s- <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 [wj�'7. Policy Number and Check to Verify <br />Insurance is Effective During Project Date <br />[vr2. Name and/or Telephone Number for or Contract Term <br />Producer Contact <br />[tT 3. Name and Address of Contractor <br />[ r] /4. Name of the Insurance Company(ies) <br />[v] /5. Boxes Checked Identifying the Type of <br />Coverage <br />[ ] 6. Additional Insured. Box May be Checked <br />,v14 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 />[q- 8. Correct Coverage Dollar Amounts Listed <br />[rte]- 9. Project Description by Number or Location <br />(if applicable) <br />[,]— 10. Name of City and Address <br />[v] 11. Insurer's Signature Required <br />not the contractor's signature) <br />[ ®] 12. To Approve, 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 Storck x 5207 <br />7-re-D T V <br />176 <br />