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Contract Insurance Certification Checklist <br /> Contractor Name: City of Redwood City Contract Nwmber: <br /> Form Completion Date: Jaly 12,2013 Form Completed By: Mary Vozikes <br /> i. Dces the contractor carry 51,000,000 or more in comprehensive general liability insurance?(ForHealth System orrty,does the <br /> professional(A�ID,psychologist,nurse)work in u hospital,•setting where the facility will cover the general liability?) <br /> � Y� p rro� <br /> 2. Dces the contractor travel by car to provide contract services? <br /> � Yes ❑ No* <br /> (a) If yes,does We co�ractor catry$1,000,000 or more in motor vehicle liability insurance? <br /> � Yes ❑ No* <br /> 3. Does the contractor have 2 or more employees? <br /> � Yes ❑ No* <br /> (a) If yes,does the contractor carry statutory limits(see handbook)for Workers' Compensation Insurance? <br /> � Yes ❑ No* <br /> 4. Is this a contract for professional services(state certification,architect,accountant,physician,etc)? <br /> � Yes ❑ No* <br /> (a) If yes,does the contractor carry professional liability insuranoe? <br /> � Yes ❑ No* <br /> 5. Did you make any changes to the Hold Harmless clause in the contract template? <br /> ❑ Yes � No* <br /> (a) If yes,did Risk Management and County Counsel approve changes to contract template? <br /> � Yes ❑ No* <br /> 6. Is San Mateo County named as the certificate holder/additianal insured? <br /> � Yes ❑ No* <br /> *N"No"is checked in anv�'the Ligbli�U�boaes{#��Zsi,�i3�,#4a,#5a,or#�—cs�ll Risk M�nagement for further <br /> ....othern-ise,this form is complete. Attach to ins�uance certificate and keep��-ith contract. <br /> COMN�NTS: <br /> 5e�►�i�f�� ; .�a!��#�►1€�c �'����;��� <br /> Risk Mans�gement has re�-iew-ed�nd appro�•ed modification or wai�•er of insurance requirements for this contract. <br /> Signature: Date: <br /> F«�►;�a by c�y a�n�g�°S o�rce-�n 1,2oi2 <br />