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CITY OF SANTA ANA <br />RISK MANAGEMENT a division of HUMAN RESOURCES <br />Managing Risk naarxjh Pos*m Change <br />Affidavit of Exemption for Workers' Compensation Insurance <br />Pat Hurley <br />(NomeI771tle) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of City of Santa Ana <br />(Consultant/Company Name) <br />that during the term <br />of my contract for Guitar Instruction 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: 10/30/2023 <br />Print Name: pat Hurley <br />Print Title: Guitar Instructor <br />Signature: <br />Telephone: 714 904-9310 <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\Insurance Requirements\ Affidavit of Exemption for Workers' Compensation Insurance 2021 <br />