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CITY OF SANTA ANA <br />RISK MANAGEMENT a dtrwuee 4 HUMAN RESOURCES <br />Ma 09N Rts9c &vL%* POMM Orange <br />WORKERS' COMPENSATION DECLARATION <br />I, gOSgh4 lMA/ hereby affirm under penalty of perjury, the <br />(Nome/Title) <br />following declaration: <br />I certify on behalf of uVgfi�rvyii r0 Tromim4 that during the term <br />(Consultant/Company Name) <br />of my contract for trgi n i nq 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: 4' 1 1 Z'7- <br />Print Name: gpsona Lomeli <br />Print Title: -AlUh4 <br />Signature: 44d <br />Telephone: p3J_W-g W' <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />SHALL SUBJECTAN 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: kRisk Mgmt�lnsurance Requiremental WC Declaration 08152019 <br />RIAMV g.n dDivisim <br />RVIEWtD6 APPRO BY: <br />A+.�g Au*44 <br />�, <br />Risk Management Speoa st <br />