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County 41 Altaterla <br /> Request torkistitenne Wilverer'Champ. <br /> 01;be complajed brffie.Guntracting Deptethathe• <br /> Fax or 01C to:Risk Managemord Unit. <br /> Fax 272-6816a14815 F CZ 28505 <br /> Mn.:Contract Review: Karen Coolie Rhone: 3724371 <br /> . . <br /> (Sr.RfektinsuranceanaimG <br /> -„, <br /> BW1111te Rama Ellen De Guzman Dept.: BCD. <br /> Phone 6704436. CIC: 60706 Fax. 670.6378 <br /> . . <br /> Date ofRequest June it2otL known of Contract-41623411HOME Terre of Cited itfTh%SSA MOM . <br /> Narne.oftontrattor. . City of Pleaamton <br /> 1. What do you want towaive or-change(W=a-ahre and --..therispir. <br /> a) Coverage(a): Generattitily Professienettelnify_ Woes'*MO <br /> _—.04weReoutred.Coverageg <br /> br-OramettErnitel0err*MtleNt/:---fintr4t4000;000 . -- pet ttmenariee <br /> kftoLaity .7"1.Fiekir.000,-000:04 - •-Paftectitenbe <br /> _ ---arotaisformaialap—Rent4000.000-04.- <br /> tt RtSaory- riCeittit tat- <br /> • Requestle00044.11sen--Covesagelketthiyathimeatert0--____4114wathava4OMMeitestheeter,--wfl reineurantertethrelhothintarttetwbeine):tES ' <br /> & --For WorkareConipensation Waiver.please tave-Conlitototallat tits <br /> Doelatios: <br /> Wzdtrearctlotheabovemonionedlreihmersmarmannzethaethetethansassemste*Yeet _ <br /> othettlentlihe masa officers,directors,pertness ot other pnnotpalowto baveteleotoi to beixemptftem; <br /> Worker's Compensation tateame in accordance with Calirrain taw.. <br /> I fetter warrant stlimdentanditit requkeancilsznocitiottj700.etsoti:dike <br /> - Code withrespect to providing Workeeteoropeasation.caveniga:forimy•employtes of flit:450yo foaltiOni4 <br /> business.I tweet°comply with the code requirements and ell.edieemmtleable laws mutregulattone sesteAteg- <br /> maize COMPagatiOnt Pan/11100A Fielking WswidthelOthent01404aK enipkolownt Pea liner Vie <br /> to hold die ConeryefAlernedsbaimipeLthwm_lpes-st ErEbry1iEdilTreyiessofkomtheSerflie thew <br /> nvaitioncausinessto comity with arw seclitoie Of regolada I thSretplest that the COunG of <br /> Alemedewaistitsrequiranentfor evidenceotNitedopeasidiereineiWwww4ecoizeletiers <br /> abcisit-tekenbtworic <br /> Sliplator0 — <br /> O'.w,Offfar,Direhlor,Pertigiship' citheitrinciptl Lie <br /> • Pthirftrielame <br /> 4 Ff941,1444it,bi copra thadors of&aka-BdilititAatithed: <br /> . . <br /> ThIstection btOoSpleted by Risk Management <br /> kletitly RIM°County' <br /> Wotan Granted 1<ented_. Change: Qat_ Derthitzt <br /> COnekkeitions: A VendoceCooPolor Prowam been-*elopedtor contaidaswin do nothave or camotaticalthe required <br /> Seaga Penne coated Me Rek UM kr <br /> ituthorhad*stature: <br /> Recittnet <br />