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Margaret Taylor, Director, Health Services <br />Independent Contractor/ <br />Page 2 <br />REMINDER: Exhibit "A" must be attached and must provide information required by paragraphs 1, 2, and 5 of <br />the Agreement form. Special terms and conditions may also be included in Exhibit "A." If Contractor will provide <br />services directly to the public, Attachment I must be completed pursuant to Administrative Memorandum E-3. <br />Insurance: Conditions of PARAGRAPH 6 met? Insurance limits under $1,000,000, if any, approved by Risk <br />Management? Yes No (Waived) <br />(If "NO," written waiver of the unmet condition(s) or lower limits must be obtained from the Department of <br />Human Resources, Risk Management Division, and submitted with this recommendation.) <br />CERTIFICATES OF INSURANCE with Additional Insured Endorsements must be submitted to Health <br />Services with the proposed Agreement. Contractors who have no employees must sign a statement to this effect in <br />lieu of submitting evidence of Workers' Compensation Insurance. <br />Requested by (contact person) / d~ ~t1~Ls ext. <br />Department or Division Head Approval <br />Date of Approval <br /> <br />b - S -D3 <br />