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CITY OF SANTA ANA , s A <br /> RISK MANAGEMENT a division of HUMAN RESOURCES i <br /> Managing Risk dam,Positive Change <br /> Affidavit of Exemption for Workers' Compensation Insurance <br /> I, Franklin Haynes hereby affirm under penalty of perjury, the <br /> (Name/Title) <br /> following declaration: <br /> I certify on behalf of Franklin Haynes Marionettes that during the term <br /> (Consultant/Company Name) <br /> of my contract for marionette puppet shows 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: 2/20/24 <br /> Print Name: Franklin Haynes <br /> Print Title: Puppeteer <br /> Signature: <br /> Telephone: 800-687-5393 <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 /> Risk 114magement Diviskin <br /> ,Wci REVIEWED&APPROVED By: <br /> A3 AcI 4 <br /> Rislc tAanagement Specialist <br /> I:\Risk Mgmt\Insurance Requirements\Affidavit <br /> cxernNuun lur vvurltws �uiFI}J F' ation Insurance 2021 <br />