Laserfiche WebLink
CITY OFSANTA ANA <br />RiSH MANAGEMENT. dmbua. 4HUMAN RESOURCES <br />Managing Risk vywph Postthm Charige <br />WORKERS' COMPENSATION DECLARATION / <br />) <br />I, �j V hereby affirm under penalty of perjury, the <br />(NomelTtle) <br />following declaration: <br />I certify on behalf oftaezd!! L4�A TiW-.47t7 that during the term <br />(CansukonUCompony Name) <br />of my contract for /2es/:5! /1/ 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: /�V2L Z <br />Print Name: /? IAy <br />Print Title: <br />Signature: <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 ADDITION TO THE COST OF COMPENSATION, DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />REVIEWED & APPROVED <br />By Risk MANAGEMENT DIVISION <br />APRJ§ 2020 <br />ANC,iE ACEvcdo <br />I.IRhk Mgmtllnsumme RequiremenalwC Oechmran 08252019 <br />