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CITY OF SANTA ANA F s <br /> RISK MANAGEMENT a du [aa°6 HUMAN RESOURCES C.. <br /> Managing Risk an Positive Change <br /> WORKERS' COMPENSATION DECLARATION <br /> Rachael Wallman/Owner hereby affirm under penalty of perjury, the <br /> (Name/Title) <br /> following declaration: <br /> I certify on behalf of Doodlebugs Animal Adventures that during the term <br /> (Consultant/Company Name) <br /> of my contract for Live Animal Presentation 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: 5/14/24 <br /> Print Name: Rachael Wall man <br /> Print Title: Owner/Educator <br /> Signature: a ,�� <br /> Telephone: 657-333-8016 <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 /> \ f <br /> a e w; Risk ManagementDMslon <br /> 1% •'• REVIEWED&APPROVED BY: • <br /> Risk Management Specialist <br /> I:\Risk Mgmt\lnsurance Requirements\WC Declaration 08152019 <br />