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N-2016-142-01 <br />WORKERS' COMPENSATION DECLARATION <br />I _Monica Robles DBA Heart Centered Leadership Coachinga <br />and Consulting Group hereby affirm under penalty of perjury, the <br />(Nametride) <br />following declaration: <br />I certify on behalf of _Monica Robles DBA Heart Centered coaching <br />and Consulting Group that during the term of my <br />(Consultant/Company Name) <br />contract for —Training_., v� services with the City of Santa Ana, I <br />will 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: _Aug. 21". 2018 <br />By: __Monica Robles DBA Heart <br />Centered Coaching and <br />Consulting Group <br />Name: Monica Robles DBA Heart <br />Centered Coaching and <br />Consulting Group --- <br />Title: -....--President, <br />Telephone: (480) 518-5557 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE, IS <br />UNLAWFUL, AND SMALL SUBJECT AN EMPLOYER TO CRIMINAL PENALIIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO TI`IE COSTOF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTOR'NEY'S FEES. <br />