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CITY OF SANTA ANA <br />RISK MANAGEMENT. thaw&( 4HUMAN RESOURCES <br />ManagN Risk oma;h PosiWe aural <br />WORKERS' COMPENSATION DECLARATION <br />i, Pat Hurley <br />(Nome/Title) <br />following declaration: <br />I certify on behalf of Pat Hurley <br />hereby affirm under penalty of perjury, the <br />that during the term <br />(Consultant/Compony Nome) <br />of my contract for guitar instruction 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: 9/24/2021 <br />Print Name: Pat Hurley <br />Print Title: Guitar Instructor <br />Signature: rk <br />Telephone: 714 904-9310 <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 />P�Risk Mgmtlinsurance Requirementsi WC Declaration 08152019 // <br />tS� %,<f�rcrs:om <br />RNM1Mnny<iinl <Inul Nile <br />