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CITY OF SANTA ANA <br />RISK MANAGEMENT a division of HUMAN RESOURCES <br />Managing Risk eywah Positive Change <br />Affidavit of Exemption for Workers' Compensation Insurance <br />RYAN TOOMIRE rpenalty of PeIjU[ Y, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of ITS FOAM TIME <br />(Consultant/Company Name) <br />that during the term <br />of my contract for FOAM PARTY services with the City of Santa Ana, <br />(Type 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: MARCH 24 2024 <br />Print Name: RYAN TOOMIRE <br />Print Title: OWNER <br />Signature: I <br />Telephone: 323-438-1314 <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 />I \Risk Mgmt\Insuran ce Requirements\Affidavit of Exemption for Workers' Compensation Insurance <br />MmugnnattDfvtvian <br />REVIEWEwED & APPROVED BY: <br />Risk Management SpeciAst <br />