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CITYOFSANTAANA <br />RISK MANAGEMENT. 4wa&* 4 HUMAN RESOURCES <br />%,,maging Risk #,vtxTp F�os&t.Change <br />I \ hereby affirm under penalty of perjury, the <br />AJAxar,^4az� <br />(Nome/Title) <br />oil <br />I certify on behalf of. P1zgm)e1z P4-s-r Ji-levIc-ex O65-r-that during the term <br />(Consultant/Company Name) <br />of my contract for Xr 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: <br />Print Name: <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 ATTORNEYS FEES. <br />1:Risk h4gmtllnsurance Requirements� WC Declaration 08152019 <br />RwEwED & AmovED Or <br />Rmk M—g—n Clmif ) Aide <br />