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CITYoFSANTAANA <br />RisK MANAGEMENT Aww4w HUMAN RESOURCES <br />Managing Risk omq�o Poshtm Change <br />WORKERS' COMPENSATION DECLARATION <br />6 LA) 6 el III. <br />�ts^1 q S rY hereby affirm under penalty of perjury, the <br />(NamelTitle) <br />following declaration: <br />I certify on behalf of -VAeo FA / ► rVI(16that during the term <br />(Cons Vto n tlComp an y do m e) <br />of my contract for 111Ae-,c>"-JfrA 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: / - 77- 2- 6� / <br />Print Name: -17� E <br />Print Title: (3 Lo A er <br />Signature: <br />Telephone: <br />19/ 4- - 3 94�; - Z/- <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 Mgmt\lnsurance Requirements�WC Declaration 08152019 <br />Risk MwaganedDMsiun <br />REVIEWED & APPROVED BY.- <br />F04c"�" Z vk" <br />RtWjanagementftalpt <br />