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CITYOF SANTAANA <br />RISK MANAGEMENT d&&,oa 4HUMAN RESOURCES v <br />M naginq Risk ai% .. Posiow Change <br />WORKERS' COMPENSATION DECLARATION <br />Martin Torres <br />(NamelTitle) <br />following declaration: <br />I certify on behalf of <br />of my contract for <br />hereby affirm under penalty of perjury, the <br />Martin Torres <br />that during the term <br />(Consultant/Company Name) <br />Martial Arts - Karate Do Kiai 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: Sept 1, 2021 <br />Print Name: Martin Torres <br />Print Title: Martial Arts Instructor <br />Signature: <br />Telephone: (A 4) 497-9267 <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.�Risk Mgmt1lnsurance RequirementsJWC Declaration 08152019 <br />�,. Risk Mvvgmt dDMs1on <br />�. REm kso&Arraovmer: <br />®' Risk Management Malyrt <br />