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CITY OF SANTA ANA , _;:T, <br /> RISK MANAGEMENT diaiaiacc eic HUMAN RESOURCES f ',- <br /> Managing Risk through Positive Change , 4(617-V: <br /> Affidavit of Exemption for Workers' Compensation Insurance <br /> Cesar A. Vargas, Executive Director hereby affirm under penalty of perjury, the <br /> (Name/Title) <br /> following declaration: <br /> I certify on behalf of MENTE, Inc. - Cesar Vargas&Associates that during the term <br /> (Consultant/Company Name) <br /> of my contract for Translation/Interpretation 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: August 1, 2024 <br /> Print Name: Cesar A. Vargas <br /> Print Title: Executive Director <br /> Signature: Caeb', 'y'-) <br /> Telephone: 714-987-2889 <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 /> I:\Risk Mgmt\Insurance Requirements\Affidavit of Exemption for Workers'Compensation Insurance 2021 <br />