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I <br />CITY OF SANTA ANA <br />RISK MANAGEMENT. dur� 4 HUMAN RESOURCES <br />Managing Rim armv45 PosWve <br />WORKERS' COMPENSATION DECLARATION <br />Diane Gladwell, President <br />(Name/Title) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of Gladwell Governmental Services, Inc. that during the term <br />(Consultant/Company Nome) <br />of my contract for Records Management Consulting services with the City of Santa Ana, <br />(Type of service provided) <br />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: 4/2/2021 <br />Print Name: Diane R Gladwell <br />Print Title: President <br />Signature: 7?60VXC )e 4&40e,� <br />Telephone: (909) 337-35 6 <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 />l: Risk Mgmt�lnsuronce Requirements�WC Declaration 08152019 <br />Risk MwugmwdDWum <br />' REVIEWED & APPRovED By. <br />3 <br />z <br />�� Risk Management Analyst <br />