Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />Sonia Miskulin <br />(NameMfle) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />I certify on behalf ofAcademy of International Dance that during the term of my <br />(ConsuhanUCompany Name) <br />contract for Recreation Classes 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: 04/23/2019 <br />By: CtD� <br />Name: Sonia Miskulin <br />Title: Recreation Instructor <br />Telephone: <br />(714) 550-9285 <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 />wed b'! <br />evie <br />pRC <br />