Laserfiche WebLink
('11T OF 5ANrA ANA <br />R�M MANAGEMENTm d��w" 4 HLOAAN RESOUACES <br />WinaqVic), R[Sk Oww'w, h POSItIve Change )'V <br />Affidiavit of Exemption for'Worker�'Compensatiojn Insurance <br />John, M. Raya, FounderlPiresiderd hereby affirm, under penalty of perjury, the <br />following declaratlon: <br />I certify on behalf of T'KO Youth Foundation ("TKO") that during the 'terra <br />(r-- orn pan y No ff m?) <br />of my contract for after school youth program services Mth the City of Santa Ana, <br />dype of.,erwc, pwvido� <br />I wRI not employ any, person hn any manner so as to become subject to the workers' <br />cornpensatoon Iaws of CaVornia, and agree that if I should become subject to, the <br />workers'compensation provisions of Section 3700 of the Labor Code, I shall forthwth <br />comply, with the proviis�ons and provide proof of workers' compensatbn coverage <br />rnmediately., <br />Date", <br />. .. . . .. ....... <br />Print Name: <br />........ . . ) ,, �4i . ......... . . . . <br />'r <br />... . . . .......... . .... .. .. .. Print Tulle. <br />Signature 16%�, <br />Telephone:,—,,, . .... . . . .. . ........... <br />WARNING„ FAtiLIJRE TO SECURE WORKERS' COMPENSA70N COVERAGE IS UNLAWFUL, AND <br />SHALL. SUBJECT' AN EMPLOYER TO CRIME NAL PENALTIES AND CIVL FINES UP TO ONE HUNDRED <br />THOUSAND DOLLARS ($100,004 IN ADMTION TO THE COST OF COMPENSAWN, DAMAGES AS <br />PROVIDED FOR VN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, <br />L\Risk Mgnij,a�nsurance RequirermLnts'n Affidavat of exemption for Workers'Compensation IUn-wrancie 2021 <br />Rick Management Division <br />REVIEWED & APPROVED BY: <br />Comm <br />I Risk Monagewnt Analyst <br />