Laserfiche WebLink
CITYOFSANTAANA <br />RISK MANAGEMENT dav4e« 4HUMAN RESOURCES <br />Managing Risk rrr ,- Positive Change ' I; <br />WORKERS' COMPENSATION DECLARATION <br />Sandra Bryant, CEO hereby affirm under penalty of perjury, the <br />(Nomel`l-itle) <br />following declaration: <br />I certify on behalf of Elite Command Training that during the term <br />(Consultant/Company Name) <br />of my contract for CLASSROOM INSTRUCTIONAL 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: December 21. 2020 <br />Print Name: Sandra Bryant <br />Print Title: CE <br />Signature: <br />Telephone: 626-290-6007 <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 />1:1Risk Mgmtllnsurance Requirements`lWC Declaration 08152019 <br />RiakMm.ge nedDlvisian <br />[REAEwm & APPROVED Br. <br />P,. <br />® Risk Management Analyst <br />