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CITY OF SANTA ANA <br />RISK MANAGEMENT. say..a,. ,y HUMAN RESOURCES <br />Managing Risk iivucKu� Positive Change <br />WORKERS' COMPENSATION DECLARATION <br />r <br />(Name/Title) <br />following declaration: <br />I certify on behalf of Recreadon passes <br />hereby affirm under penalty of perjury, the <br />that during the term <br />(Consu$ony'Compony Name) <br />of my contract for Dance and yoga instruction services with the City of Santa Ana, <br />(Type of servke 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: 10:312019 <br />Print Name: ChihiroSano <br />Print Title: Dance and yoga Instructor <br />Signature: <br />Telephone: --- <br />71 4_913-5W <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 />\CEMENT DIVISION <br />19 2019 <br />M. I.AMRFRT <br />