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CITY OF SANTA ANA <br /> Risk Management a division of Human Resources <br /> Managing Risk through Awareness and Action <br /> AFFIDAVIT OF EXEMPTION FOR AUTOMOBILE LIABILITY INSURANCE <br /> 1,_ —("Representative"),attest that 1 am an authorized <br /> (Name and TitleorVcndo(ftepresentrrtivo) <br /> representative of � �� ("Company"),and <br /> (Consultant/Company Nonte) <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—JY—Z-0 21-�'F 1,y <br /> ("Agreement")to provide �-0 etJ.( t-G pa..... &4("Services"): <br /> (Sor oes 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 /> document and does not maintain the minimum automobile liability insurance coverage as <br /> required in the Agreement, it will be considered a breach of Agreement rendering the Agreement <br /> null rind void and Company will be fully liable for any and all damages. <br /> Signature bate <br /> Print Name <br /> Tido <br /> Cnnturl.Lilnrmaliorr,is!,l'elophone Number aiidhx Email Address <br /> Affidavit of Exemption For Autornobile W)WIlty Insurance 11,12.2024 <br />