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CITY OF SANTA ANA ,,: <br /> Risk Management a division of Human Resources <br /> Managing Risk through Awareness and Action <br /> AFFIDAVIT OF EXEMPTION FOR WORKERS' COMPENSATION INSURANCE <br /> I MthotyyiWdMaAmieoWc r TtraCtor "Re resentative"( p ), attest that I am an authorized <br /> (Name and Title of Vendor Representative) <br /> representative of�/ tffi ("Company"), and <br /> (Consultant/Company Name) <br /> possess the authority to legally bind Company. <br /> In my capacity as Representative of Company, I represent and confirm the following, as relates to the <br /> agreement between Company and City of Santa Ana, agreement number P&A 1 <br /> ("Agreement")to provide EF& trWtwlw' it tt avIl a4"t ("Services"): <br /> (Services to be provided under agreement/contract) <br /> During the course and scope of Company's agreement with the City of Santa Ana, Company will <br /> not employ any person in any manner so as to become subject to the workers' compensation laws <br /> of California, and agree that if Company should become subject to the workers' compensation <br /> provisions of Section 3700 of the Labor Code, Company shall forthwith comply with the <br /> provisions and provide proof of workers' compensation coverage immediately. <br /> If at any time it is found that Company is not adhering to any and/or all of the statements in this <br /> document and does not maintain the minimum professional liability insurance coverage as <br /> required in the Agreement, it will be considered a breach of Agreement rendering the Agreement <br /> null and void and Company will be fully liable for any and all damages. <br /> RMM <br /> *Sign. � Date <br /> c+ c+ e+ Print Name <br /> t l).C7�11 LF�dRyelW Y�lW l�lY{9LN�1��l� <br /> Title <br /> 1 / <br /> Contact Information,i.e.,Telephone Number and/or Email Address <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, <br /> AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO <br /> ONE HUNDRED THOUSANT DOLLARS($100,000).IN ADDITION TO THE COST OF <br /> COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> INTEREST,AND ATTORNEY'S FEES. <br /> Affidavit of Exemption for Workers'Compensation Insurance 11.12.2024 <br />