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CITY OF SANTA ANA <br />RISK MANAGEMENT a division of HUMAN RESOURCES <br />Managing Risk ryvgp,, Poshim Cheri i�� <br />Affidavit of Exemption for Workers' Compensation Insurance <br />Devin Dailey/ President <br />(Name/Title) <br />following declaration: <br />certify on behalf of Merritt Studio <br />hereby affirm under penalty of perjury, the <br />that during the term <br />(Consultant/Company Nome) <br />of my contract for Design Services _ services with the City of Santa Ana, <br />(Type of service 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: 6/17/24 <br />Print Name: Devin Dailey <br />Print Title: President <br />Signature: -OeAvtw-Oakley <br />Telephone: 949.370.3824 <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 />Risk Management Division <br />Reviewed and Approved by: <br />c�ti .ae <br />Risk Manager <br />I:\Risk Mgmt\Insurance Require ments\ Affidavit of Exemption for Workers' Compensation Insurance 2021 <br />