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QrvoFSAiYTAANA <br />RISK MANAGEMSWV , & ala.. 4 HuwAN RESOURCES <br />hianag4tp Milk 7av V, Podlutk.. [0nngp `' U <br />WORKERS' COMPENSATION DECLARATION <br />1, Ana Guillen hereby affirm under penalty of perjury, the <br />(Name/ritle) <br />following declaration: <br />I certify on behalf of Get CPR Cart. ted that during the term <br />2C MWtaar OaWan➢Name] <br />of my contract for Reereadon Class services with the City of Santa Ana, <br />MPe ofsenQe provided) <br />I will not -employ any person in any manner so as to become subject to the workers' <br />compensation laws of California, end agree that if I should become subject to the <br />workers' compensation provisions ofsection 3700 of the Labor Code, I shall forthwith <br />comply with the provisions and provide proof of workers' compensation coverage <br />immediately. <br />Date: 4/4/2022 <br />Print Name: Ani Quillen <br />PrintTfee: Owner, Get CPR Certified <br />OII:HH�NMObe.. <br />Signature: Ana Gttiftejn <br />Teisphone: 662445,0207 <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 />1=lRlsk Mgm[Ifnsvmnce Requlmment,IWC Oedarvion 08152mg <br />.,, FtiMmS{anmkDAWm <br />_.. � Renec4naMvwvmsr: <br />7orc Dlewaa <br />ib�&tavugmm,O�a1NAe <br />