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C177OFSANTA ANA <br />RISH MANAGEMENT d4.a&- 4HUMAN RESOURCES <br />NLIn. 1giny Rrsk . Positive Ch.mge EE� <br />WORKERS' COMPENSATION DECLARATION <br />Yessica Campos <br />(NomelTitle) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of City of Santa Ana <br />of my contract for <br />that during the term <br />(Consultant/Company Name) <br />Recreation Classes 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: November 19,2019 <br />Print Name: Yessica Campos <br />Print Title: instructor <br />Signature: <br />Telephone: 71 <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 />REVI ED &APPROVED <br />y Ris AN!C MEM DIVISION <br />20 2019 <br />--- --- - — -- - - SAMANiHA M. LAMBERT- - - - -- ----- <br />1:IRisk Mgmthnsurance RequirementslWC Declaration 08152019 <br />