Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />I LaVerne Davis <br />(Name/Title) <br />following declaration <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of —LaVerne Davis that during the term of my <br />(Consultant/Company 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: Jul 2, 2019 <br />LaVerne Davis <br />By: <br />Nam <br />Title: Recreation Instructor <br />Telephone: <br />657-235-7262 <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 />REVIEWED & APPROVED <br />By RISK MANAGEMENT niViSlON <br />vS P D3 Q1g <br />FRANCINE R. VILLAREAL <br />