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Prison to Employment Implementation Direct Services Grant <br />Form 5: Workers' Compensation Certification EDD RFA#84049 <br />YAV R.!SERS' G P NSATIQ CERTIFICATION <br />The undersigned in submitting this document hereby certifies the following: <br />I am aware of the provisions of section 3700 of the California Labor Code which requires every <br />employer to be insured against liability for workers' compensation or to undertake self - <br />Insurance in accordance with such provisions before commencing the performance of the work <br />of this Agreement. <br />Samantha M. Lambert Risk Management Sup <br />Name and Title (Printor Type) <br />City of Santa Ana <br />Firm Name <br />14-Feb-19 <br />Date <br />20 civic Center Plaza <br />Street Address <br />Santa Ana, <br />City, State, Zip <br />