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CITY OFSANTA ANA <br />RISK MANAGEMENT a d&a4o%* 4 HUMAN RESOURCES <br />hlarTayhg Risk nvmpn Posldve Cl nige - <br />WORKERS' COMPENSATION DECLARATION <br />I, #AW ramU5. hereby affirm under penalty of perjury, the <br />(Name/rifle) <br />following declaration: ` <br />I certify on behalf of ay, �A?L+% that during the term <br />(Consul ton t/Company Name) <br />of my contract for (M1QI Ix, services with the City of Santa Ana, <br />(Type o/ 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 />Date: " i N I I q <br />Print Name: <br />Print Title: ►1 (� !L <br />Signature: <br />Telephone: I LI . gel Wls� <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 />& APPROVED <br />\CEMENT DIVISION <br />19 2019 <br />SAMAINTHA M. LAMBERT <br />1:IRisk Mgmtl,nsurance RequirementslWC Declaration 08152019 <br />