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CrrroFSAivTAAlvA <br />RISK MANAGEMENT,. Awa... (HUMAN REsouRCEs <br />Managing Risk rmcfrPw tive Change <br />WORKERS COMPENSATION DECLARATION <br />1, Brittany/ Instructor hereby affirm under penalty of perjury, the <br />(Name,/rafe) <br />following declaration: <br />I certify on behalf of myself that during the term <br />fCanwerunr/r mPartyNarwl <br />of my contract for Zumba Instructor services with the City of Santa Ana, <br />(Type of aervicE 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: 6)1)22 <br />Print Name: Brittany Perez <br />Print Title: Zumba Instructor <br />Signature: <br />�%n (LGV%� tD�rer'V <br />Telephone: (714) 376-9 72 <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 />L1,Rb*,Wgmr1i MnW ReyuirementrlVXVedarotim 08152019 <br />cnwa¢ vwuion <br />o= `�,. RenEwm6AraRovm Br. <br />' Risk Management Specialist u <br />