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Ct7Y of SA aTA AkA <br />RISK MA ACDAEh'T < &.ems nF HJefai. azso'-Rms <br />Mart S" M* aorWn iamkire Charge <br />Affidavit of Exemption for Workers' Compensation Insurance <br />Jorge Melgota, president <br />(Nome/rule) <br />following declaration: <br />F7�4-J <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of Ardent Ergonomics that during the term <br />(Consultont/Cornpan7 NeTei <br />of my contract for preventative ergonomic assessment 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: <br />Print Name: - Alle-0oze- <br />Print Title: Qf�steAn <br />Signature: <br />Telephone: &e - <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 />IARisk Mgmt\Insurance Requirements\ Affidavit of Exemption for Workers' Compensation Insurance <br />Ride Managanmt Division <br />REVIEWED6 APPROVED BY: <br />Fk� Z V:,U.cnrdE.' <br />® Risk Management Mzlyrt <br />