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CITY OFSANTA ANA <br />RISK MANAGEMENT. di.6vr 4HumAN REsouRCET <br />ti^snaySng Risk uywzhPosltive Change <br />D <br />/ <br />WORKERS' COMPENSATION DECLARATION <br />/.1 <br />hereby affirm under penalty of perjury, the <br />(Nome/title) <br />following declaration: 1-74 <br />I certify on behalf T, V 4- L7 that during the term <br />(ConsuftantlComponY Name) <br />of my contract for Qesc,� M/ 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 />Print Name: <br />Print Title: <br />Signature: <br />Telephone: <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 & APPROVED <br />By Risk MANAGEMENT DIVISION <br />APRJ§ 2020 <br />ANGIE ACEVEdo <br />MMA Mgmtllnsum"e RequireMMAWC OedaWtbn 08252019 <br />