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County of Alanieda <br /> Request for Insurance Waiver or Change <br /> (Fa be completed bitheZontrecting Deparhnent) <br /> Fax or'QIC to: Reit( Management Unit <br /> Fax 272-6815 or 2-6815 1 CIJC 26505 <br /> Attn.: Contract Review: Karen C aoDe Phone: 273571 <br /> (Sr: Risk Insurance Analyst) <br /> Fax Back to: Name: _Ofeen De Guzman Dept: HCD <br /> Phone: 670 ClIC .50708 Fac 670-6378 <br /> Date of Request June 13, 2011_ Amount of Contract 8209,894Th ONIE,_ Tenn (Molted: 711/11 <br /> Name of Contractor. City of Sah Leandro <br /> 1. Whit do•you want to waive or change (W and Ccchange)? <br /> a) Coverage r (e): 'General liability ProfessIcnalliablli& Werlieri Canqi <br /> Other Required Coverages <br /> b) Change m Cleft General Liability: From 31,008,000 MS' . per occurrence <br /> • <br /> Auto Liebllity: Frork 61,000;600M 3' . per .oteinienee • <br /> Professional liabBly: From $1,000.000 to $ . per daub <br /> Other Coverage Lirnit <br /> b) Reason: "Cent( Dent <br /> 2. Requeatior Time Waiver: Coverage(s) 61 PL, WC #of daysrequestect. Tbisallowsroontracter <br /> • bind the insurance before te. Contract term. begins). needlirtle <br /> 3. For Workers' Compensation Waiver, please ham CtinttactOr Sign thrirdeClaratton: <br /> DccIaratio <br /> With respect to theabove-mentita*ttlinsMeSs [hereby :W01W Otaithe-besineas.liaa no eiciployees <br /> outer ThEall4c 9.focOrs,•cirectlias. paiTilets.PX. be exemPi frum <br /> Workers .Gamptimiticin coverage xn accordance <br /> farther warrant that 1 widefedind the requiferamats' of Sectiod3Met seq. of California Labor <br /> Code with-resPectto previdinglYmite Compensation coveragefOranyemployees of:the-above mentioned <br /> business. 1 agme -to comply with the code requiremina-Mand a1Lath.applicab1c fews.and regidationsregerding <br /> workers . compensation, payroll taxes, FICA and tax withholding and similar employnattit iesuee. fiirtber <br /> to hold the-Comfy of Alameda harmless from loss or liabilitj-Whiehmay'ariso 4tinatlae.failine orthe *eye- <br /> mentione,d business to done/Ay with any such laws or reigU1titibus."7 of <br /> Alamedawaive its requirement far evidence cifWO:Acme GoropenseninirkturenceM COlittltekitiri with the <br /> • <br /> above-refecerieed work. <br /> Signature <br /> Ownel, Officer, Director, Ponmaillip or cater Principal Date <br /> "tint/Type Name <br /> 4. • Please -attach a copy of the Scope of Services.-Exhibit kAttached <br /> ■Inattretk*errtewkati-lirtilett***;;•••,..:44•••4*.-kii•-•erttra,,44.....t.o.****....”......- <br /> This Section to b nOleted by Risk Managemnt e <br /> Identity Risk to County: <br /> Waiver: Grant De0100 Change: Granted Denied <br /> Considerations: A Venrinetturizector lorjce Program has • evelaped tor codratfbrs wire do ecitheve otativiotalibid Me-required <br /> knife:Mee. Mese contact fflj:4 eme Untkir recnelAvr <br /> / <br /> Authorized Signature: Data: <br /> Rev: atina <br /> • <br />