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COMPANY NAME AND PROJECT INSURANCE VERIFICATION FORM CITY OF REDWOOD CITY It is hereby understood and agreed that the following insurance requirements are applicable to this project and that the applicable policies and/or endorsements contain the fonowing coverage. (Please check (,/) to indicate coverlllle.) V"Additionallnsured for General Liability and Auto Liability Coverage The CitY of Redwood CitY. its Council. commissions. committees. boards. officers. emolovees. and agents as additional insureds as resDeCts to work done by Named Insured. ---------------- ----_u / Primary Coverage /A'rimary Coverage, General Liability V'" Primary Coverage, Auto Liability With respect to claims arising out of the operations of the Named Insured, such insurance as afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the above Additional Insureds. ------- Cross Liability! Severability of Interest ~'CJ"OSS Liability, General Liability /Cross Liability, Auto Liability '-- The naming of more than one person, finn or corporation as insured under this policy shall not, for that reason alone, extinguish any rights of the insured against another, but this endorsement, and the naming of multiple insureds, shall not increase the total liability of the Company under this policy. - // Notice of Cancellation for General Liability and Auto L~bility It is understood and agreed that in the event of cancellation of the Policy for any reason, including non-payment of prerniwn, 30 days written notice win be sent to the following holder by mail: ........ . .."'" ... ... ...... ..... . City of Redwood City P.O. Box 391 Redwood City, CA 94064 Attn: Engineering and Construction (650) 780-7380 - Phone . . .... .",::~~:;~~]!?:":?~~;:~g,:....... -:.:.:.:.:....:.:.:.:.:.:.:.:.:.:.:.:':.:.:.:':.:.:.:.:.:.:.:.:':.:.:':':':.:':.:.:.:.:':.:.:':.:.:. ..... ............................"............. ... ......... .'.'.'.'.... .'.'.'.'.'.'.'.'.'.'.'.'.'.','.',','.'.'.'.'.','.'.'.'.'.'.'.'.','.',','.',',','.'.'. ::::::':':':':':':':'........,..........':::-:"':','.':::'.':':':'.. .':::""':':':-:::-:'.. .':':':':':-:,":-:':':':-:':-:':-:':':':':':':-:':':':':':-:':.:.:.:,:,:,:.:.:.:.:-:.:-:-:.:.:.:.:.:-:-:.:':.:".:::':.:.:':':':-:-:':':':-:':':':':::':':':':............':':':':.:.:.:-:.:.:,:,'.:.:.:.:-:.:.:-:.:.:-:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:-:.:':.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:-:-:.:':':.:.:.:.:.:.:.:.:.:.: PLEASE FILL IN THE SPACES BELOW AND RETURN WITH A CERTIFICATE OF INSURANCE TO THE ADDRESS LISTED ABOVE. General Liability 1.~.2ID-á3 tí-~' I ~. /4¿:/~ Policy No. Effective Date: Expiration Date Name of Insuruce Carrier/Comp Authorized Representative - r