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CITY OF SANTA ANA <br />RISK MANAGEMENT a d4*zoa 4 HUMAN RESOURCES <br />Managing Risk #wia, Posl&e Change <br />WORKERS' COMPENSATION DECLARATION <br />Miguel Torres Cruz <br />(Name/Title) <br />following declaration: <br />I certify on behalf of <br />of my contract for <br />hereby affirm under penalty of perjury, the <br />that during the term <br />(Consultant/Company Nome) <br />The artist Grant 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 />Michael -Miguel Productions <br />Date: 3/5/21 <br />Print Name: Miguel Torres Cruz <br />Print Title: Producer <br />Signature: <br />Telephone: 714-914_5877 �J <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 ADDITIONAL TO THE COST OF COMPENSATION, DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />l:I Risk MgmtlInsurance Requirements �WC Declaration 08152019 <br />Rkk Management Analyst <br />