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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: C <br />Date Certificate of Liability Insurance Submitted: 17 /l3 ! f t> <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 />^" y Insurance is Effective During Project Date <br />[ ] 2. Name and/or Telephone Number for <br />Producer Contact <br />[ <br />-r3. Name and Address of Consultant/Sub <br />[✓]-'4. Name of the Insurance Company(ies) <br />[ �,r5. Boxes Checked Identifying the Type of <br />Coverage <br />[ r6. Additional Insured Box May be Checked <br />and Separate Additional Insured <br />Endorsement Form Must Be Attached <br />(make sure the endorsement lists the <br />insurance policy #) and Verify Primary <br />Language on Acceptable Additional Insured <br />Endorsement <br />or Contract Term <br />kl__�8. Correct Coverage Dollar Amounts Listed <br />[' Professional Liability Insurance Listed (if <br />architect, engineer, attorney or accountant) <br />11-rio. Project Description by Niumber or Location <br />(if applicable) <br />[ 11. Name of City and Address <br />[ - 12. Insurer's Signature Required <br />not the consultant's signature) <br />[ 7 i3. To Approve, Write "Reviewed by [sign <br />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 />