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Set(ice Contract <br /> Page 5 <br /> <br /> REQUIRED COVERAGES - Where "X" Appears In Box CERTIFICATES OF INSURANCE <br /> 6. Other (cont%nued) <br /> Name <br /> Address <br /> Clty, State, ZIp <br /> <br />7. Self-Insurance <br /> <br />/__/Contractors self-%nsured for any r~sks shown ~n Secttons above shall attach to <br /> contract evidence satisfactory to County of Contractor's f~nanc~al abll~ty Isuch as <br /> a current f~nanclal statement) to respond to losses ~n amounts shown above, for <br /> each risk self-insured. Contractor shall complete and s~gn the following statement <br /> and attach to contract. <br /> <br />The Contractor Is self-lnsured for the following coverages with respect to th~s contract: <br /> /__/ Worker's Compensation <br /> <br /> /__/ Comprehensive General L~abll~ty to the l~m~t of $ <br /> <br /> /x/ 8odtly injury <br /> /x/ Property damage <br /> /x/ Blanket Contractual <br /> / / Personal ~n]ury ' <br /> / / Products/completed operations <br /> / / Broad form property damage <br /> /_._/ Fire damage legal l~abtl~ty <br /> <br /> /__/ Comprehensive Auto L~ab~l~ty to the ltmlt of.$ <br /> <br /> / / Owned Automobiles <br /> / / Non-owned automobiles <br /> /__./ Mired automobiles <br /> <br /> /__/ Professional LIability to the llmlt of $ <br /> <br />Note: If excess Insurance ls needed to meet the llmlts required for Insurances In <br />Exhibit C, then the authorized representative of the excess Insurance company(s) must <br />stgn the cert%f%cates In Exhlblt C pertaining to the necessary coverages. <br /> <br /> SIgnature of authorized Tltle Date <br />representative of Contractor <br /> <br />2507I - 10/24/86 <br /> <br /> <br />