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6.D. - Page 104 of 170 <br />Request for Qualifications: <br />General Park Building Construction, Retrofit, Maintenance, and/or Repairs <br />FORM C <br />City of Los Angeles <br />Applicant's Declaration of Self -Insurance <br />It is hereby RESOLVED that: <br />Name and Address of tlrgaougaetioar <br />which is a ❑ For profit Corporatio40 Roo-IWfit Corporation, Lf General Qa¢tnenhip, U L:immited Puxineeship>U Sale Propsielo <br />❑ Qther: has a fa mw programm, to self -insure exposure ih the amount <br />� af�aara{�l <br />Of 3 per ocruatemce, and S annual aggregate limit and agrees to the following temms and conditions: <br />l . To provide the Gilt of Los Angeles (City) the same defense of suits and payment of claims as wouldbe afforded by forst dollar <br />insumuCp with respect to iD opemmliws .bar which City has issued a permit, lease, comp xt, w odor aglemmull 0 meinaiter <br />Ag a mmeadl. <br />3. During the term of the A peenum with C*, to provide annually an audited fmauctal statememu that gives etridemme of capacity <br />to respond to claims within the selfimsured retenth m listed abode- Failure to provide such fi naw -W infermati mn may be <br />grounds for dirapgroalal of this self-insurance pxop mm and may came suspension or Nation of Agteenment with City_ <br />(Most recent staftmemt is atladmd) <br />3. To mortify the cognizant City AgeengiBureau immediately of any claims, judgement, set lemem award, verdict or change in <br />financial stamdim g which would sub m ntially affect the protection that this s elf4msuranc e program provide s and to provide City <br />at least 30 days prior written notice of event to discontinue this self-mstuance pmog mm. <br />Declara lion <br />The Undersigned hereby declares: that this resolution has been adopted in accordance with applicable lace and any <br />other governing documents„ that Aho program is mow in force and that the persons whose signatures appear hereon are auth,amized to act as <br />stated in the Resoh7 on. <br />Time Undersigned herewith trammils this form. along with any other evidence of insurance which may be req&M. to <br />tatty AdmInlalrative 011laer. Risk Mainaglemsnk 200 North Main Stmet. Room 1240. Clay Hall Fist. Los Angatss. CA 9ao7R for appmal <br />prior to the start of the o!pezatian or tenancy. <br />Bsecutedthls AW of <br />Telephone: <br />0 , at <br />tPulm <br />and <br />and <br />name <br />Wryte' Toto off [urs m7Gt siva far a com ation <br />City AgemTlBureau Applicability: This �!�!?�aPPlissm�fidUauicg <br />spoa5cp®t, lmsa, a agroamoot vainh�a Ch7r. <br />IMPORTANT — RESPONDERS MUST SUBMIT ALL REQUIRED FORMS (COMPLETELY FILLED 187 <br />OUT) BY RFQ SUBMITTAL DEADLINE. <br />Pave 97 of 103 <br />