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CITY OF SANTA ANA <br />RISKMANAGEMENT. d[aeml 4 HUMAN RESOURCES +") <br />Managing Risk Posfttve Change — ; � <br />WORKERS' COMPENSATION DECLARATION <br />I, Sig 4n) V66K Fk"1CQeA) hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of.5I0'Moie/that during the term <br />(Consultant/Company Name) <br />of my contract for 1?14,J ,,TevT- dwSit.Q{1Al2 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: (p�/70L1 <br />Print Name: 4/i V6(rj4 <br />Print Title: <br />i <br />Signature: /LP�CAIT <br />Telephone: 95�-�zi �570 <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,IRisk Mgmtllnsurance Requirementsl WC Declaration 08152019 <br />REVIEWED & APPROVED BY. <br />FIA.6 44 Z V; &IaAl <br />Risk Management Anatyst <br />