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CITY OF SANTA ANA <br /> Risk Management a division of Human Resources , <br /> Managing Risk through Awareness and Action w` <br /> AFFIDAVIT OF EXEMPTION FOR AUTOMOBILE LIABILITY INSURANCE <br /> /` <br /> 4)c. { - tf,fri ("Representative"),attest that I am an authorized <br /> (Nome mid Ilk of Vendor Representative) <br /> representative of /C 6-'eti!/ E, PO4 a ("Company"), and <br /> (ctaleuitnnl/L:ompnny Name) 1 <br /> possess the authority to legally bind Company. <br /> In my capacity as Representative of Company,I represent and confirm the following,as relates to the <br /> agreement between Company and City of Santa Ana,agreement number <br /> ("Agreement")to provide ("Services"); <br /> (Services to be provided under agreement/contract) <br /> During the course and scope of Company's agreement with the City of Santa Ana, <br /> Company employees,consultants, representatives, and agents will not use and/or drive <br /> any Company owned/rented/leased/borrowed vehicles to perform Services to, for,or on <br /> behalf of City of Santa Ana. <br /> If at any time it is found that Company is not adhering to any and/or all of the statements in this <br /> doe 'tnd does not maintain the minimum automobile liability insurance coverage as <br /> required in the greement, it will he considered a breach of Agreement rendering the Agreement <br /> ull and void an Colman will be fully liable for any and all damages. <br /> ‘S•-• 01/49 <br /> Si nature Dale <br /> Eflf C (4V64- , Cif, 1 <br /> Print Name • <br /> / f <br /> rill, APPROVED <br /> By Cynthia Mora at 2:01 pm, Nov 19, 2024 <br /> 3 <br /> Cunlact I, <br /> a <br /> orritation ,Telephone Number and/or Email Address <br /> Affidavit of E><emptlon for Automobile Liability Insurance 11.12.2024 <br /> 9 /9 d Z£59# b00Lb986b6t uwinuo 'aa £Z:£t 6Z0Z'SZ'LZ <br />