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ti =x+ilk � r <br />2015 IMR 25 A4 9: �, , <br />CITY ®I,� <br />CLERK OF CITY OF SANTA ANA <br />OFFICE OF THE CITY ATTORNEY <br />Certificate of Liability Insurance <br />Checklist for Contractor Policies <br />Name of Contractor: SOFTMA 5TCR. , S'roC <br />Date Certificate of Liability Insurance Submitted: V25"Lz 0 15 <br />Permit No. Issued: <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 />[y}"1. Name and Address of a Producer [�J' 7. Policy Number and Check to Verify <br />Insurance is Effective During Project Date <br />[v]�2. Name and /or Telephone Number for or Contract Term <br />Producer Contact <br />[v]' 3. Name and Address of Contractor <br />[L�- 4. Name of the Insurance Company(ies) <br />[ q-5, Boxes Checked Identifying the Type of <br />Coverage <br />[� 6. Additional Insured Box May be Checked <br />`f and Separate Additional Insured <br />Endorsement Form Must Be Attached (make <br />sure the endorsement lists the in® ance -Is <br />policy #) and Verify Primary Language on <br />Acceptable Additional Insured Endorsement <br />[a'' 8. Correct Coverage Dollar Amounts Listed <br />[vK. Project Description by Number or Location <br />(if applicable) <br />[v]°10. Name of City and Address <br />[x]--11. Insurer's Signature Required <br />(not the contractor's signature) <br />[L]--12. To Ap rp ove, Write "Reviewed by [sign <br />your name]" on Every Page of the <br />Certificate of Insurance and all <br />Endorsements and Write the Number of <br />Pages (ex. 1/4 or 4/4) 212 J 1201 S <br />Contact the City Attorney's Office if you have any questions — Lisa Storck x 5207 <br />