Laserfiche WebLink
CITY OF SANTA ANA <br />RISK MANAGEMENT. Glm, a 4HUMAN RESOURCES _1 <br />iManagfng Risk Mrougn POsliflfe Change ) <br />WORKERS' COMPENSATION DECLARATION <br />1,°b d,/ °w"hereby affirm under penalty of perjury, the <br />(Nome/Title) <br />following declaration: <br />I certify on behalf of �/a!� Jisg�cra j that during the term <br />(Consultant/Company Name) <br />of my contract for ✓e� ,� s0/0LC, 7 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 />late: <br />me: <br />itle: <br />�ure: <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 />kl Risk Mgmt1lnsurance Requirements)WC Declaration 08152019 <br />