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C1TYoi1$ANiAANA <br />RISK MANAOEMEN-r o rdt mo* 4HUMAN RESOURCES <br />Managing RM *vqA Posiuva Change t <br />WORKERS' COMPENSATION DECLARATION <br />I, � �/ hereby affirm under penalty of perjury, the <br />(Namejl"ttleJ <br />following declaration: <br />I certify on behalf of_ ���_��"s 4:' g. ?-- _ that during the term <br />(ConsultanVCompony Name) <br />of my contract for �ervices with the City Of Santa Ana, <br />Type of service provldedJ <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 />Date; <br />Print Name: <br />Print Title: <br />1 <br />Telephone,J J <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />SHALLSUBJECT 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 />& APPROVED <br />�GFmFm DiViSION <br />4 2019 <br />l:IRisk Mgmtllnsurance RequirementslWC Declaration 08152019 <br />