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CITY OF SANTA ANA <br />RiSK MANAGEMENT 4vaeoa 4 HUMAN RESOURCES <br />Mar%3,5jfii,g Risk awuopoyly CIVAI <br />...... ...... . -1— I'll-- . ... .... .... <br />hereby affirm under penalty of perjury, the <br />(No litle) <br />eclarati followi �Iejl <br />I certify on behalf of rffthat during the term <br />10� <br />(Consul kn)lCompony Nome) <br />of my contract for 0', yliM services with the City of Santa Ana, <br />(T'yp4 of service provid <br />I will not employ any person in any =ner 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: <br />Print Title: <br />Signature: <br />Telephone: <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 Mgmtllnsurance Requirements\WC Declaration 08152019 <br />RiEmEwm &APPROVED Or <br />