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CITYOFSANTAANA <br />RISK MANAGEMENT d&Q4w 4HUMAN <br />r.�SO�RESO99URC��ES _ <br />WORKERS' COMPENSATION DECLARATION <br />I Kevin Dalrymple/Judo Instructor hereby affirm under penalty of perjury, the <br />(Nomelhtle) <br />following declaration: <br />I certify on behalf of <br />that during the term <br />(Consultant/Company Name) <br />of my contract for Recreation Classes services with the City of Santa Ana, <br />(Type of service provided) <br />I 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 the provisions and provide proof of workers' compensation coverage <br />immediately. <br />Kevin Dalrymple <br />Date: 11 /19/2019 <br />Print Name: Kevin Dalrymple <br />Print Title: Judo Instructor <br />Signature: <br />Telephone: 714-235-3811 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED <br />THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />REVIEWED & <br />By Risk I VNAgi <br />I:iRisk Mgmttlnsuronce RequirementstWCDeclaration 08152013AMANTHA M. <br />