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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: <br />Date Certificate of Liability Insurance Submitted:,, <br />Permit No. Issued:—A <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 />2. Name and/or Telephone Number for <br />Producer Contact <br />3. Name and Address of Contractor <br />V4 4, Name of the Insurance Company(ies) <br />YJ 5. Boxes Checked Identifying the Type of <br />Coverage <br />s4i G. 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 />X 7. Policy Numb er and Check to Verify <br />Insurance is Effective During Project Date <br />ZD <br />or Contract Tera.. <br />�q S. Correct Coverage Dollar Amounts Listed <br />DQ 9,. Project Description by Number or Location <br />(if applicable) <br />M 10. Name of City and Address <br />K11, Insurer's Signature Required <br />(not the contractor's signature) <br />X4 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 />