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CITY OF SANTA ANA <br />RISK MANAGEMENT dtacaiaa 4HUMAN RESOURCES <br />Managing Risk PosItIn Change <br />WORKERS' COMPENSATION DECLARATION <br />l Guy Abramovitz, CFO <br />(Name/Title) <br />following declaration: <br />I certify on behalf of Kajeet, Inc. <br />of my contract for SmartBus <br />hereby affirm under penalty of perjury, the <br />(Consultant/Company Name) <br />that during the term <br />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: 8/30/2024 <br />Print Name: Guy Abramovitz <br />Print Title: Chief Financial Officer <br />Signature: <br />Telephone:9/-694-0245 <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 />1: Risk MgmtVnsurance RequirementslWC Declaration 08152019 <br />RiA Muagemenf Diwiun <br />Rene D&APPRav®BY: <br />®' <br />Risk Management Specialist <br />