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CaTroP SANTA ANA <br />RI51f MANAGFJv6NT,n Aawae" 4 HURAN RESOURCES <br />WORKERS! COMPENSATION DECLARATION <br />I, Ana GUlilen hereby affirm under penalty of .perjury, the <br />(Name/7irle) <br />following declaration: <br />I certify on behalf of Get CPR Certified that during the term <br />x0mvitant%cbmpanyfName) <br />of my contract for Recreation Class services with the City of Santa Ana, <br />(Type of service pravlded) <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_ 4/4/2022 <br />Print Name: Ana GUi'llen <br />PrIntTltie: Owner, Get CPR Certified <br />Signature: 'Ana \.7 U.I.II$'n uN' <br />��aMM+erv�um.n <br />ox ww:aw. <br />cw s ynn.urmo��a<o,n:.o-xe <br />onm:muw.a+.lzv:rmm <br />Talaphone: 562-445-0207 <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 ATTDRNEY'S FEES. <br />klftk Mgmt`insumnce Reguiremen(si IC Aeclarmtian W152019 <br />i <br />e '�. WdlM�wgemmkUi,Wm <br />`7orl ,preu+e,a <br />` — - Rishhl,aeemmKlniralAiae <br />