Laserfiche WebLink
CITY OF SANTA ANA <br />OFFICE OF THE CITY ATTORNEY <br />Certificate of Liability Insurance <br />Checklist for Consultant/Sub-recipient Policies <br />Name of Consultant/Sub-recipient: 0,Ft,,V.a„^1,�L-� <br />Date Certificate of Liability Insurance Submitted: <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 />[4 1. Name and Address of a Producer <br />[ K2. Name and/or Telephone Number for <br />Producer Contact <br />[-f 3. Name and Address of Consultant/Sub <br />[ 4-�4. Name of the Insurance Company(ies) <br />[ ,J`�5. Boxes Checked Identifying the Type of <br />Coverage <br />[ ] 6. Additional Insured Box May be Checked <br />and Separate Additional Insured <br />[,f'7. Policy Number and Check to Verify <br />Insurance is Effective During Project Date <br />or Contract Term <br />Correct Coverage Dollar Amounts Listed <br />[vf 9. Professional Liability Insurance Listed (if <br />architect, engineer, attorney or accountant) <br />[,T10. Project Description by Number or Location <br />(if applicable) <br />[ <br />el 1. Name of City and Address <br />Endorsement Form Must Be Attached [✓] 12. Insurer's Signature Required <br />(make sure the endorsement lists the (not the consultant's signature) <br />insurance policy #) and Verify Primary <br />Language on Acceptable Additional Insured [ ] 13. To Approve, Write "Reviewed by [sign <br />Endorsement your name]" on Every Page of Certificate <br />of Insurance and All Endorsements and <br />Write the Number of Pages (ex. 1/4 or 4/4) <br />Contact the City Attorney's Office if you have any questions - Lisa Storck x5207. <br />