Laserfiche WebLink
CITY OF SANTA ANA 0. 8 A <br /> RISK MANAGEMENT a division of HUMAN RESOURCES a' <br /> Managing Risk through Positive Change <br /> IF DSO. <br /> Affidavit of Exemption for Workers' Compensation Insurance <br /> Maria Madrigal / Individual hereby affirm under penalty of perjury, the <br /> (Name/Title) <br /> following declaration: <br /> Icertify on behalf of Maria Madrigal that during the term <br /> (Consultant/Company Name) <br /> of my contract for Zumba instructor 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: 12/23/2024 <br /> Print Name: Maria Madrigal <br /> Print Title: Individual <br /> Signature: !, _! <br /> Telephone:p 714 878-1498 <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 />