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0TYOFSANTAANA <br />RISK MANAGEMENTa dio[ecou 4HUMAN RESOURCES <br />Managing Risk m t Positive Change ) <br />WORKERS' COMPENSATION DECLARATION <br />I, k a, ' �� hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of Liz _ that during the term <br />(Consultant/Company Name) <br />of my contract for Arc .,_/1// �, xr. its^ 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 />Date: 'Il-,Zo/A/ <br />Print Name: Obtimb •.sl, <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 ADDITIONAL TO THE COST OF COMPENSATION, DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />RBE IIiEWM D & APPRANACiEMENIpOV ION <br />AR <br />k: RiskMgmtllnsuranceRequiremenislWCDeclaration 08152019 <br />