Laserfiche WebLink
• <br /> WORKERS' COMPENSATION DECLARATION <br /> Martha Van Rooijen hereby affirm under penalty of perjury,the <br /> (Name/Title) <br /> following declaration: <br /> I certify on behalf of MVR Consulting that during the term of my <br /> (Consultant/Company Name) <br /> contract for On-Call Software Maintenance services with the City of Santa Ana, I will <br /> and Development Support Services <br /> 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 those provisions and provide proof of workers' compensation coverage. <br /> DATE: July 11, 2024 <br /> By: MVR Consulting <br /> Name: Martha van Rooijen 2Vd,( <br /> Title: Owner <br /> Telephone: 909 709 7505 <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br /> UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br /> AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN <br /> ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR <br /> IN SECTION 3706 OF THE LABOR CODE, INTEREST,AND ATTORNEY'S FEES. <br /> ,, „ RieleManegemealDivisian <br /> 3i% li‘ REVIEWED&APPROVED BY: <br /> 'I' p ' A ACZ1/441 <br /> Risk Management Specialist <br /> 1 <br />