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SA}�� <br /> A Y <br /> ` � l <br /> Managing Risk through Awareness & Action <br /> r�IFO��• <br /> Risk Management Division <br /> Human Resources Department <br /> Affidavit of Exemption for Worker's Compensation Insurance <br /> Lisandro Orozco, Owner <br /> I/We, , hereby affirm under penalty of <br /> Name,Title <br /> perjury the following declaration: <br /> I certify on behalf of Santa Ana History that during the term of the <br /> Consultant Name/Company Name <br /> agreement for Photography services with the <br /> Type of Services to be Provided <br /> City of Santa Ana, I will not employ any person in any manner so as to become subject to the <br /> Workers' Compensation laws of the State of California and agree that if I should become the subject <br /> to the Workers' Compensation provisions of section 3700 of the California Labor Code, I shall <br /> forthwith comply with the provisions and provide proof of workers'compensation insurance <br /> coverage, as required under the terms of the relevant agreement, immediately. <br /> 6/3/2024 <br /> Date: <br /> Signature: 7 <br /> Lisandro Orozco <br /> Print Name: <br /> Owner <br /> Print Title: <br /> 714-673-5504 <br /> Telephone: <br /> WARNING: California Labor Code § 3700.5 states in relevant part: <br /> (a) The failure to secure the payment of compensation as required by this article by <br /> one who knew, or because of his or her knowledge or experience should be reasonably <br /> expected to have known, of the obligation to secure the payment of compensation, is a <br /> misdemeanor punishable by imprisonment in the county jail for up to one year, or by <br /> a fine of up to double the amount of premium, as determined by the court, that would <br /> otherwise have been due to secure the payment of compensation during the time <br /> compensation was not secured, but not less than ten thousand dollars ($10,000), or <br /> by both that imprisonment and fine. <br /> Updated 6/3/2024 I:\Risk Mgmt\Insurance Requirements\Affidavit of Exemption for Workers'Compensation Insurance <br />