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CITY OF SANTA ANA " <br />OFFICE OF THE CITY ATTORNEY <br />Certificate of Liability Insurance <br />Clieddist for Contractor Policies <br />Name of Contractor: <br />Date Certificate of Liability Insurance Submitted: 1 / - a - i —7�_ <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 />[� 1. Name and Address of a Producer [✓r 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 Tern <br />Producer Contact <br />[`r 3. Name and Address of Contractor <br />[v]'4. Name of the Insurance Company(ics) <br />[v]'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 (make <br />sure the endorsement lists the insurance <br />policy #) and Verify Primary Language on <br />Acceptable Additional Insured Endorsement <br />[y" 8. Correct Coverage Dollar Amounts Listed <br />[ ] 9. Project Description by Number or Location <br />(if applicable) <br />[ ] 10. Name of City and Address <br />[ ] 11. Insurer's Signature Required <br />not the contractor's signature) <br />[ ] 12. Tcv A r rove, Wnto"Reviewed by [sign <br />your natne]" on Every Page, of tile <br />Certilictttc of InhnrtinCe and all <br />i;ndorscru lits and Write Elie Number of <br />I'¢tgew (ex,_ 1/4 or 4/4) <br />Contact the City Attorney's Office if you have any questions — Lisa Storck x 5207 <br />