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CITY OF SANTA ANA <br />RI5K MANAGEMENT da ae" "HUMAN RESOURCES ���y <br />Managing Rlsk arwoug* PoWn Change a �.k n <br />-( <br />WORKERS' COMPENSATION DECLARATION <br />I Jeanette Pletcher <br />(Name/Title) <br />following declaration: <br />I certify on behalf of Beez Kneez Creative <br />hereby affirm under penalty of perjury, the <br />that during the term <br />(Consultont/Compony Name) <br />of my contract for Education Consulting 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: 8/12/20 <br />Print Name: Jeanette Pletcher <br />Print Title: Founder <br />Signature: r.,-- C P/. <br />Telephone: 208 340 8281 <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 />l: Risk Mgmtllnsurance RequirementsJWC Declaration 08152019 <br />wakrtn��n <br />REVIE &APPRO BY: <br />�1 <br />F4AW� Z. VXA141 <br />- <br />Risk Management Mzlys[ <br />