Laserfiche WebLink
CITY OF SANTA ANA <br />RISK MANAGEMENT dG<ealaa 4HUMAN RESOURCES 3 <br />Managing Risk mrnugn Positive Change „, : 9 <br />WORKERS' COMPENSATION DECLARATION <br />Alyssa Romo <br />(Nome/Title) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of Alyssa Romo, aka Vel the Wonder that during the term <br />(Consultant/Company Name) <br />of my contract for performance 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: 8-1 g-22 <br />Print Name: Alyssa Romo <br />Print Title: Artist <br />Signature: <br />Telephone: 626�-23/5-8703 <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 />? 1 RZn4 PROV®BY: <br />I:�Risk Mgmt�lnsurance Requirements�WC Declaration 08152019 <br />