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CITY OFSANTA ANA <br />RISK MANAGEMENT* (*dates 4HuMAN REsouRCEs <br />Managing Risk owuoh PoMv Change <br />WORKERS' COMPENSATION DECLARATION <br />I, EQlreNL,4 -P�e hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of i 511 P'� 56/L n4gOtIO that during the term <br />(ConsultanVCompany Name) <br />of my contract for JJVM rv)( e services with the City of Santa Ana, <br />(Type of semice 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: ': N 1707 7_ <br />Print Name: <br />Print Title: <br />Signature: <br />Telephone: Q <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 />I.Mlsk MgmAinsurance RequimmentslM Dedararion 09152019 <br />_p., REv �� fi�ol% . <br />T.y Jrwo�a <br />94�� Risk tAanagement Analyst <br />