Laserfiche WebLink
CITY OF SANTA ANA <br />RISK MANAGEMENT d&,&j" 4HUMAN RESOURCES <br />I i <br />Affidavit of Exemption for Workers' Compensation Insurance <br />PM,, nP�i[�( I�O hereby affirm under penalty of perjury, the <br />mettle) <br />following declaration: <br />I certify on behalf of Ilnl I S��I N �� �/�%��� ���_ that during the term <br />(Consultont/Compony Name) <br />of my contract for enit' �G l 8�1- OC�7— 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: 114 1 % <br />Print Name: <br />Print Title: <br />Signature: <br />Telephone: <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 />RiA M,ougrMad D welon <br />ReoE D&APPRW®Br. <br />A-j�, Aa4° <br />® RiA Management Spedalht <br />I:\Risk Mgmt\Insurance Requirements\Affidavit of Exemption for Workers' Compensation Insuran <br />