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CITY of SANTA ANA <br />RISK MANAGEMENT a 4wacaa ad HUMAN RESOURCES <br />Managing Wk ~ Positive Change <br />WORKERS' COMPENSATION DECLARATION <br />I, A R*H�hl(N M hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of Myself (Adriana Martinez) that during the term <br />(Consultant/Camponyy Name) <br />of my contract for . 'yU� (_i(l&ervices 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: <br />Print Name: <br />Print Title: <br />Signature: <br />Telephone: <br />FA <br />�.�. n0011 UPME <br />• !� <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 1N SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />I:�RlskMgmtklnsuranceRegulrementSkWCDeclaration 08152019 <br />�3 REVIEWED& APPROVED By. <br />' �user,�.c.c �, U:,ffsauk <br />1 Risk Management Analyst <br />