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SUPPLEMENTAL INSURANCE CHECKLIST <br />TO: CLERK OF THE COUNCIL OFFICE <br />FROM: CONTRACT ADMINISTRATOR: Commander Claborn EXT,:8274 <br />NAME OF CONSULTANT / PARTY: Filler Security Strategies Inc <br />AGREEMENT NUMBER (IF APPLICABLE): <br />Please review the Insurance section of the agreement to ensure all necessary certificates of insurance 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 0 ❑ <br />HIRED ® ❑ <br />OWNED 171 ❑ <br />GENERAL LIABILITY m ❑ <br />PROFESSIONAL LIABILITY ® ❑ <br />WORKER'S COMPENSATION ❑ Ea <br />REVISED; 9119/2018 <br />