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CITY OF SANTA ANA <br /> Risk Management a division of Human Resources <br /> Managing Risk through Awareness and Action <br /> AFFIDAVIT OF EXEMPTION FOR WORKERS' COMPENSATION INSURANCE <br /> ("Itepresentative").attest that I am an authorized <br /> (Name and Titic o vendor Representative) <br /> representative of .1-2— �� LL—L (..Company'.).and <br /> (Cons�mVCompany Nance) <br /> possess the authority to legally bind Company. <br /> In my capacity as Representative of Company. I represent and confirm the following.as relates to the <br /> agreement between Company and City of Santa Ana,a.-r/cement number <br /> ("Agrccmcnt')to provide S"./ j �l�G�-�+ (..Services"): <br /> (Services to be provided tinder agreement/contract) <br /> During the course and scope of Company's agreement with the City of Santa Ana.Company will <br /> not employ any person in any manner so as to become subject to the workers'compensation laws <br /> of California.and agree that if Company should become suhiect to the workers'compensation <br /> provisions of Section 3700 of the Labor Code.Company shall forthwith comply with the <br /> provisions and provide proof of workers' compensation coverage immediately. <br /> If at any time: it is found that Company is not adhering to any and/or all of the statements in this <br /> document and does not maintain the minimum professional liability insurance coverage as <br /> required in the Aurccment. it will be considered a breach of Agre cincnt rendering the Agreement <br /> null and void and Company will be fully liable for any and all damages. <br /> 40A <br /> si,nature Date <br /> CJ• L/yY� <br /> Print Name <br /> Az): <br /> -rise <br /> 01 <br /> Contact Intonnation.i.c..Telephone Number and/or Entail Address <br /> WARNING: FAILURE TO SECURI:WORKERS'COMPENSATION COVERAGE IS UNLAWFUL. <br /> AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PT NALTTES AND CIVIL.FINES U11'170 <br /> ONE:I IUNDRED TIIOUSANI'DOLLARS(S100.000).IN ADDITION"rO TI IL'COST OF <br /> COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF TI IE LABOR CODE. <br /> INTERL:Sr.AND ATTORNEY'S FEES. <br /> Affidavit of Exemption for Workers'Compensation Insurance 11.12.2024 <br />