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CITY OF SANTA ANA <br />*FFICE OF THE CITY ATTORNEY <br />Certificate of Liability Insurance <br />Checklist for Contractor Policies <br />, <br />Name of Contractor: 1, P's <br />I <br />Date Certificate of Liability Insurance Submitted: <br />Permit. No. Issued: 4 2wo i - <br />Steps: (a) Obtain Copy of (Current) Contract; (b) Identify Insurance Paragraph in Contract; <br />(c) Review Irisurance 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 />I. Name and Address of a Producer 7, Policy Number and Check to Verify <br />Insurance is Effective During Project Date <br />2. Name and/or Telephone Number for or Contract Tenn <br />Producer Contact <br />M3. Name and Address of Contractor <br />KI 4, Name of the Insurance Company(ies) <br />S. Boxes Checked Identifying the Type of <br />Coverage <br />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 />8. Correct Coverage Dollar Amounts Listed <br />9. Project Description by Number or Location <br />(if applicable) <br />t?q, <br />V10. Name of City and Address <br />I t. Insurer's Signature Required <br />(qot 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 bane any questions — Lisa Storck x 5207 <br />