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CITYOFSANTAANA <br />RISK MANAGEMENT a d& aewt 4 HUMAN RESOURCES <br />ManagingRisk Pcsfflw Change <br />WORKERS' COMPENSATION DECLARATION <br />dLAM er <br />I, /riemgs 1� y S rry hereby affirm under penalty of perjury, the <br />(Name/Title) I�— <br />following declaration: <br />I certify on behalf of V e_10 FAJ I l S rV CAthat during the term <br />p (Consbitont/Company Arne) <br />of my contract for Ili o ev fi>°c A "�2ry('jO 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: /7— 2 �� <br />Print Name: 6M9 S 17yS�� <br />Print Title: ! Il <br />0 Lon er <br />Signature: Ir> <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 />l: RiskMgmtVnsuranceRequirements�WCDeclaration 08152019 <br />RiskMwagxmentDMsian <br />REVIEWED&APPROVED BY: <br />'� Risk Management Analyst <br />