Laserfiche WebLink
CITY OF .SANTA ANA <br />RISK MANAGEMENT a da aeoa 4 HUMAN RESOURCES <br />Ma�'ng Ilk Pasidw CharnVg` <br />WORKERS' COMPENSATION DECLARATION <br />Ruby Gutierrez <br />(Name/Title) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />certify on behalf of Ruby Gutierrez that during the term <br />(Consultant/Company Name) <br />of my contract for grant assistance 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: 5/27/2021 <br />Print Name: Ruby Gutierrez <br />Print Title: <br />Signature: <br />Telephone: (661) 369-4464 <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 />1: Risk Mgmt�lnsurance Requirements�WC Declaration 08152019 <br />o� x <br />Risk MwaganerdDMsiun <br />ccREVIEWED & APPROVED BY: <br />T PZ. V <br />Risk Management Analyst <br />