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CITY OFSANTA ANA <br />RISR MANAGEMENT. d/<wu' 4HUMAN RESOURCES _ <br />Managln,I Risk a wth Posldve Change <br />WORKERS' COMPENSATION DECLARATION <br />I, f►�I� f (lYAk5, hereby affirm under penalty of perjury, the <br />(Nome/Title) <br />following declaration: <br />I certify on behalf of AMM tyAlLro that during the term <br />(Consultant/Company Name) <br />of my contract for (M1C(I I ngyKdrr-, 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 />Date: it 1N I&1 <br />Print Name: OVI C1+,� 115 <br />Print Title: t1 <br />Signature: <br />Telephone: �' LI . 3q,.1 � t5 <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 />\DEMENT DIvI5i0N <br />19 2019 <br />MRisk Mgmtjlnsumnce Requirements) WC Declaration 08152019 <br />