HOME CONSORTIUM (2016) C-13846 - Laserfiche WebLink

County of Alameda Request for insurance Waiver or Change (To be completed by the Contracting Department) Fax or QIC to:Risk Management Unit Fax 272-6815 or 2-6815 / QIC 28505 Attn.:Contract Review: Karen Caoile Phone: 272-3871 (Sr.Risk&.insurance Analyst) Fax Back to: Name: _Eileen De Guzman Dept.: HCD Phone: 670-6436 QIC: 50708 Fax: 670-6378 Date of Request: 6117116 Amount of Contract: 15,185_Term of Contract: 7/1/16 thru 6/30/20 Name of Contractor: City of Pleasanton 1. What do you want to waive or change(W=waive and C=change)? a) Coverage(s): General Liability b) Change In Limits: General Liability: From$1,000,000 to$ per occurrence Auto Liability: From$1,000,000 to$ per occurrence Professional Liability: From$1,000,000 to$ per claim Other Coverage Limits: b) Reason:_ 2. Request for Time Waiver: Coverage(s) GL,AL,WC #of days requested: 45 (This allows Contractor time to bind the insurance before the Contract term begins) Insurance'effective until 6/30/16 need waiver to request for contract number. 3. For Workers'Compensation Waiver,please have Contractor sign this declaration: Declaration: With respect to the above-mentioned business,I hereby warrant that the business has no employees other than the owners,officers,directors,partners or other principals who have elected to be exempt from Worker's Compensation coverage in accordance with California law. I further warrant that I understand the requirements of Section 3700 et seq,of the California Labor Code with respect to providing Worker's Compensation coverage for any employees of the above mentioned business.I agree to comply with the code requirements and all other applicable laws and regulations regarding workers compensation,payroll taxes,FICA and tax withholding and similar employment issues.I further agree to hold the County of Alameda hamiless from loss or liability which may arise from the failure of the above- mentioned business to comply with any such laws br regulations.I therefore request that the County of Alameda waive its requirement for evidence of Workers'Compensation insurance in connection with the above-referenced work. Signature Owner,Officer,Director,Parmorship or other Principal Date PrintiType Name Title 4. Please attach a copy of the Scope of Services• Exhibit A Attached. ********************8*4**t******k**i**tit******************k***t**a***************tk*****H,**t******A********itAMAMa,Ik**********t*i*tk*******'**Ikkf**** This Section to be completed by Risk Management Identify Risk to County: Waiver: Granted / Denied Change: Granted Denied Considerations: A Vendor/Contrectorinsurance Program has been developed for contractors who do not have or cannot afford the required insurance. Please contact the Risk Management Unit for more information. J Authorized Signature: `t-�^,.E.-r� �'�=-'� Date: Rev:0112008