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CITY OF SANTA ANA <br />RISK MANAGEMENT a dam 4 HUMAN RESOURCES <br />Managing Risk e►awh Posldve Chan <br />WORKERS' COMPENSATION DECLARATION <br />M.E. Raneses/Hearing Officer <br />(Name/Title) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />certify on behalf of Michael Raneses <br />(Consultant/Company Nome) <br />of my contract for Hearing Officer <br />that during the term <br />services with the City of Santa Ana, <br />(Type of service provided) <br />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: June 28, 2021 <br />Print Name: Michael E. Raneses <br />Print Title: Hearing Officer <br />Signature: 7,�iPz--Z� <br />Telephone: 714.287.4999 <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 />I:Risk Mgmt�lnsurance Requirements�WC Declaration 08152019 <br />a �ortaN Risk MwaganedDMsiun <br />3 REVIEWED & APPROVED BY.- <br />-ERisk Management Analyst <br />