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CITYOF,SSANTA ANA <br />RISK MANAGEMENT. w 4 HUMAN RESOURCES ' <br />riat NJ* positive Char1ge J <br />WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury, the <br />(Namg1T1tfe) <br />following declaration: <br />I certify on behalf of 5 &Comp;ony that during the term <br />(ConsuttNName) <br />of my contract for Tnie$� Vn ;� services with the City of Santa Ana, <br />(TYPe,v;ce grovided) <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 previsions and provide proof of workers' compensation coverage, <br />Date: 11 t <br />Print Name: r ! _ rizo i YA trl i <br />Print Title: i �1 <br />[rVIV VA l i <br />Signature: <br />Telephone d ' Li s <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 ADDITIONAL TO THE COST OF COMPENSATION, DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />kiffisk Mgmt1insurance Requirements}WC <br />08152019 <br />