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SUPPLEMENTAL INSURANCE CHECKLIST <br />v6 G3'3 <br />TO: CLERK OF THE COUNCIL OFFICE <br />71 <br />FROM: CONTRACT ADMINISTRATOR:EXT.: 7c( <br />NAME OF CONSULTANT/ PARTY: Api-cAwocT : ttc- <br />AGREEMENT NUMBER (IF APPLICABLE):./+-Z01') `36Z <br />Please review the insurance section of the agreement to ensure all necessary certificates of insurances are <br />submitted to the Clerk's Office. Please provide ALL documents listed to fully execute the agreement and <br />avoid payment delay to the vendor. <br />Please check all boxes below that apply to your agreement. <br />BUSINESS AUTOMOBILE LIABILITY <br />NON -OWNED <br />HIRED <br />OWNED <br />GENERAL LIABILITY <br />PROFESSIONAL LIABILITY <br />WORKER'S COMPENSATION <br />'1�. ❑ <br />❑ En 4.&/7- IQe owxe. a <br />1A ❑ <br />