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CITY OF SANTA ANA <br /> RISK MANAGEMENT a dizadee-oic HUMAN RE5OURCES a <br /> 171 <br /> WORKERS' COMPENSATION DECLARATION <br /> 1, Lynn Wheeler/Integrator hereby affirm under penalty of perjury, the <br /> (Name/Title) <br /> following declaration: <br /> I certify on behalf of Wild Wonders that during the term <br /> (Consultant/Company Name) <br /> of my contract for Our Animal Program 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: 05/10/24 <br /> Print Name: Lynn Wheeler <br /> Print Title: Integrator <br /> Signature: <br /> Telephone: 760-630-9230 <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 Management Division <br /> A REVIEWED&APPROVED BY: <br /> ' A Aaw4 <br /> ® Risk Management Specialist <br /> !:}Risk Mgmt}insurance Requirements}WC Declaration 08152019 / <br />