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CITY0FSAN7AANA <br />Rises MANAGEMENT.4awtau o6HUMAN RESOURCES <br />Managing RIsk unto Positive Change � <br />WORKERS' COMPENSATION DECLARATION <br />�ftl — hereby hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />certify on behalf of_2,a1ca_ that during the term <br />C'onsu! ant/Company Name) <br />of my contract for i 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 />Print Name: <br />.v` <br />Print Title: t "4 <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 (S100,000), 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 />REVIEWED & APPROVED <br />By Risk MANAr4FMENi LDivisiON <br />.RCU07 Q9 <br />FANI E R. VILLAREAL <br />k; Rlsk Mgmtltnsurance RequireinemskWCVeddrmim 081-VV19 ' <br />