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CITY DP SANTA ANA <br />RISK MANAGEMENTa 0,eu a odHUMAN RESOURCES - <br />ManagIng Risk mmmLtr Postgve Change , <br />N, 1� <br />WORKERS' COMPENSATION DECLARATION <br />I, Luis R. Martinez <br />(Name/Title) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of Luis R. Martinez that during the term <br />(Cansultant/Company Name) <br />of my contract for Mental Health counseling _ services with the City of Santa Ana, <br />(Type of service provided) <br />I will not employ any person in any manner so a.s 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 provisionsand provide proof of workers' compensation coverage <br />immediately. <br />Date: March 15, 2022 <br />Print Name; Luis R. Martinez <br />Print Title: Mental Health Counselor <br />Signature: ` — " <br />f <br />/�". y._-..e_ <br />Telephone: 114 469-401 <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 />k�Rlsk MgmtjInsurance RequirementslWC 0edaration 08152019 <br />x�.vw„,rixaaon " <br />il�}IYI "7oai �irrwa�c <br />