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CITYOFSANTAANA <br />Ri5K MANAGEMENT a d! aen 4 HUMAN RESOURCES <br />Managing Rlsk n oto PostUve Change <br />WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury, the <br />(Nome/Title) <br />following declaration: `- <br />I certify on behalf of l -� C� Pu p; Go � that during the term <br />(Consultant/ mpanyNome) <br />of my contract for o-Lk- 3�t9 �,z services with the City of Santa Ana, <br />( ypeofserviceprovided) <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: �� I I 'z3 <br />Print Name:\' 1 F A LJCe— <br />Print Title: D``z cab C <br />Signature: <br />Telephone: �J'� - <br />.Z� Ji <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:LRisk MgmtVnsurance RequirementsJWC Declaration 08152019 <br />REV�i <br />Jam, <br />'. <br />® <br />Risk Management Analyst <br />