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CITYonSANTAANA <br />Rist< MANAGEMENT. a'usto a 4HUMAN RESOURCES ' <br />Managing Risk mrwgh Positive Ci1anga � r <br />WORKERS' COMPENSATION DECLARATION <br />I Maricsa Secundo <br />(Namell-Irtle) <br />following declaration: <br />I certify on behalf of Maricsa Secundo <br />of my contract for <br />hereby affirm under penalty of perjury, the <br />that during the term <br />(Consultant/Company Name) <br />Dance 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 29, 2021 <br />Print Name: Maricsa Secundo <br />Print Title: Dance Instructor <br />Signature: <br />Telephone: i71 ) 781-9017 <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 a M,rrgarenl0l�Wn <br />y.� F�AEu2o&MPpavmOv: <br />9oxt �fawolo <br />"'" -----'"'" '"" '" IIISI<M:IIIdJ2111[III CIIYICAI/L'(1C �� <br />l: jRlsk Mgmtjlnsurance Requlrementsj WC Declaration 08152019 <br />