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WORKERS' COMPENSATION DECLARATION <br />I <br />Sara Ellis Conant hereby affirm under penalty of perjury, the <br />(NamGTitle) <br />following declaration: <br />I certify on behalf of Conant Coaching & Consulting LLC that during the term of my <br />(Consultant/Company Name) <br />contract for consulting services with the City of Santa Ana, I will <br />not employ any person in any manner so as to become subject to the workers' <br />compensation laws of California, and agree that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith <br />comply with those provisions and provide proof of workers' compensation coverage, <br />DATE: 9/25/18 ff, <br />By: )44 <br />Name: Sara Ellis Conant <br />Title: <br />Telephone: <br />415-378-4417 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, <br />Ifliy-9EWCti EiW': E'.t1N4C€ FkEF2E;iY9A (pCv ` € ) <br />--## <br />