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CITY OF SANTA fANA <br />RISK MANAGEMENT diuidiaa 4HUMAN RESOURCES <br />Managing Osidve ChIiange <br />WORKERS' COMPENSATION DECLARATION <br />EDUARDO GARCIA, PRODUCER <br />(Name/Title) <br />following declaration: <br />certify on behalf of <br />hereby affirm under penalty of perjury, the <br />that during the term <br />(Consultant/Company Name) <br />of my contract for VIDEO/MEDIA Production services with the City of Santa Ana, <br />DYNAMIC VIDEO COMMUNICATIONS <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: <br />Jan. 19th, 2021 <br />Print Name: <br />EDUARDO GARCIA <br />Print Title: <br />PRODUCER <br />Signature: <br />Telephone: <br />949 232 3220 <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 BY: <br />"° <br />wd <br />--� RFsk janagement Analyst <br />1: Risk Mgmt�lnsurance Requirements�WC Declaration 08152019 <br />