Laserfiche WebLink
CITYOFSANTel <br />ANA <br />Risi< MANAGEMENT a UMAN RESOURCES <br />Abnaging Risk ftwjo f7osldve Change. <br />WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury, the <br />(Name/Title) <br />I certify on behalf of <br />that during the term <br />of my contract for onsultontlCompany Name) <br />X)S . /A✓ services with the City of Santa Ana, <br />t f o (Type pe service P <br />rovi ed) <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: 30 <br />Print Name: <br />Print Title: <br />Signature: <br />Telephone: <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: JRisk Mgmtj Insurance Requirements � WC Declaration 08152019 <br />Risk Mwaganad DMsian <br />REVIEWED & APPROVED BY.- A44v44 <br />Risk Management Specialist <br />