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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: M i c aO V*4 <br />Date Certificate of Liability Insurance Submitted: ( 11 j 6 <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 />Insurance is Effective During Project Date <br />2. Name and/or Telephone Number for or Contract Term <br />Producer Contact <br />[x 3. Name and Address of Consultant/Sub <br />A 4. Name of the Insurance Company(ies) <br />[X 5. 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 <br />(make sure the endorsement lists the <br />insurance policy #) and Verify Primary <br />Language on Acceptable Additional Insured <br />Endorsement <br />/" 8. Correct Coverage Dollar Amounts Listed <br />Y J 9. Professional Liability Insurance Listed (if <br />architect, engineer, attorney or accountant) <br />Z 10. Project Description by Number 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 />13. 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 />