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CITY OFSANTA ANA <br />RI5K MANAGEMENT. q( HUMAN RE50URCE5 <br />Managing Risk #rough Posture 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 LO(-f- COMn�) that during the term <br />(Consultant/C mpanyNome) <br />of my contract for P" D it,.) �o �,a services with the City of Santa Ana, <br />( ype 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: o I i L I Z-3 <br />Print Name: E \ e � 1 <br />l�zc�Jn c 'tln L-oce- <br />Print Title: <br />Signature: —� <br />Telephone: %R _ ZG )I —SC6, <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 />klRisk Mgmt1lnsurance RequirementslWC Declaration 08152019 <br />w�ken� <br />RE,A w &APPRovm Br. <br />`- T40L y J" <br />Ruk Management Analyst <br />