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CITY OF SANTA ANA <br />RISK MANAGEMENT, dawata a 4 HUMAN RESOURCES � ;„ <br />Managing RIM 'y POS L Change, , � - ,4 <br />WORKERS' COMPENSATION DECLARATION <br />Darrell Wagner hereby affirm under penalty of perjury, the <br />(Nomelritle) <br />following declaration: <br />I certify on behalf of Professional Entertainment <br />(Consultant/Company Name) <br />of my contract for Entertainment <br />that during the term <br />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: 5/12/2022 <br />Print Name: Darrell Wagner <br />Print Title: CEO <br />Signature: I <br />• - i 1i=�1t��i - 1 <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 />klRisk MgmtVnsurance Requirements) WC Declaration 08152019 <br />R1ekM& A"Rnl.DiD BY: <br />REVIEWm & APPROV®BY: <br />71 <br />A+ ju Ate. <br />�Risk Management spea4ist �; <br />