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I <br />Denise Robles <br />CITY OF SANTA ANA <br />RI5K MANAGEMENT a dioc 4 HUMAN RESOURCES <br />Managing Risk thrwgh Positive Change <br />WORKERS' COMPENSATION DECLARATION <br />(Nome/Title) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of Denise Robles that during the term <br />(Consultant/Company Nome) <br />of my contract for Fitness Instructors 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: April 21, 2021 <br />Print Name: <br />Denise Robles <br />Print Title: <br />A ess Instr t r <br />Signature: <br />Telephone: <br />(714) 718-4047 <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 />I:�Risk MgmtVnsuronce Requirements)WC Declaration 08152019 <br />pykMmugmtoitD[Welan <br />4 c REMenm& pAerRavmSr. <br />ql FMLtY.:�f� M U:1Lf <br />�� Risk Management Analyst <br />