Laserfiche WebLink
CITY OF SANTA ANA <br />RISK MANAGEMENT a deco 4 HUMAN RESOURCES <br />Managing Risk e►awh Posldve Chan <br />WORKERS' COMPENSATION DECLARATION <br />Cesar Vargas/Executive Director hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />certify on behalf of Cesar Vargas & Associates / MENTE, Inc. that during the term <br />(Consultant/Company Name) <br />of my contract for Translation/Interpretation <br />services with the City of Santa Ana, <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: May 24, 2021 <br />Print Name: Cesar Vargas <br />Print Title <br />Signature <br />Telephone <br />Executive Pirector <br />- 0,zW <br />714-987-2889 <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 />I:�Risk Mgmt�lnsurance Requirements �WC Declaration 08152019 <br />a �ortaN Risk MwaganedDMsiun <br />3 REVIEWED & APPROVED BY.- <br />-ERisk Management Analyst <br />