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CITY OF SANTA ANA <br />RISK MANAGEMENT eoaeoa 4HUMAN RESOURCES <br />Managing Risk mnwgn PoOve Change <br />WORKERS' COMPENSATION DECLARATION <br />Cesar Vargas, Exec. Director <br />(Name/Tide) <br />following declaration: <br />C <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of Cesar Vargas & Associates/MENTE, Inc. that during the term <br />(Consultant/Company Name) <br />of my contract for Translation/Interpretation 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 />Date: <br />November 12, 2020 <br />Print Name: <br />Cesar Vargas <br />Print Title: <br />Executive Director <br />Signature: <br />A. [/� <br />Telephone: <br />714.987.2889 <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 />1:�Risk Mgmt�lnsurance Requirements�WCDeclarotion 08152019 <br />Risk MaugementDMsimt <br />°� RE\nE D & APPRD M BY: <br />FnF.w,6r.e �'. VttPr�uFP <br />®! <br />Risk Management Analyst <br />