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CITY OF SANTA ANA <br />OFFICE OF THE CITY ATTORNEY <br />Certificate of Liability Insurance <br />Cheddist for Contractor Policies <br />Name of Contractor: _ l vd q e� <br />Date Certificate of Liability Insurance Submitted: to hz-� <br />Permit No. Issued: A- -o 1�,.- / C9 <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 7. Policy Number and Check to Verify <br />Insurance is Effective During Project Date <br />]k 2. Name and/or Telephone Number for or Contract Term <br />Producer Contact <br />N, 3. Name and Address of Contractor <br />V, 4. Name of the Insurance Company(ies) <br />Vit]_ 5. Boxes Checked Identifying the Type of <br />Coverage <br />] b. Additional Insured Box Maybe Checked <br />and Separate Additional Insured <br />Endorsement Form Must Be Attached (make <br />sure the endorsement lists the insurance <br />policy #) and Verify Primacy Language on <br />Acceptable Additional Insured Endorsement <br />].„ 8. Correct Coverage Dollar Amounts Listed <br />K] 9. Project Description by Number or Location <br />(if applicable) <br />10. Name of City and Address <br />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. 114 or 4/4) <br />Contact the City Attorney's Office if you have any questions — Lisa Storck x 5207 <br />