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<br />WORKERS' COMPENSATION DECLARATION <br /> <br />I <br /> <br />hereby affirm under penalty of perjury, the <br /> <br />(NilnlerTitl~) <br /> <br />following declaration: <br /> <br />(Organization Name) <br /> <br />that during the term of my <br />, City of Santa Ana, I will not <br /> <br />I certify on behalf of <br /> <br />contract with the <br /> <br />employ any person in any manner so as to become subject to the workers' compensation <br /> <br />laws of Cali fomi a, and agree that if! should become subject to the workers' <br /> <br />compensation provisions of Section 3700 ofthe Labor Code, I shall forthwith comply <br /> <br />with those provisions. <br /> <br />DATE: <br /> <br />By: <br /> <br />Name: <br /> <br />Title: <br /> <br />Telephone: ___ <br /> <br />WAR]\;ING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />HNLA WFLL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (SIOO,OOO). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 Of TIlE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />