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C. Cesario Medical Consulting LLC <br /> 2024/2�p Affidavit of Exemption for Wp000rrfkkers' Compensation Insurance <br /> I, barb 0,,,t9, w�P�1i,`��t Hereby affirm under penalty of perjury, the <br /> (Name/Title) <br /> following declaration: /� 1 l�I- 1 <br /> I certify on behalf of C l e`cQa'lo lace\('1 JUl�i tfiat during the term <br /> (Consultant/Company Name) U <br /> of my contract for CtY 1a1)H-t ' alEt*-services with the City of Santa Ana, <br /> (Type of serrr c 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. I,,� l <br /> Date: all a-t-11_ <br /> Print Name: C or\ 5 C'l <br /> Print Title: nat <br /> Signature: L, L � <br /> Telephone: 305 3a( t-713 <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br /> UNLAWFUL, AND <br /> SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP <br /> TO ONE HUNDRED <br /> THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSA- <br /> TION, DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND AT- <br /> TORNEY'S FEES. patt 1 <br /> WekMamgementDMsion�(, REVIEWED&APPROVED BY: t <br /> P.O. Box 510693 I KeyColonyBeach, FL I33051 1 305 389 £ 4 <br /> ( I 4,t�p ,l=% fi Acavik <br /> ccesariomc@gmail.com 9 Risk Management Specialist sR <br />