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CITY OF SANTA ANA <br />. PROPOSAL NO. 10-7504 <br />PROPOSAL AND CONTRACT AGREEMENT <br />WORKERS' COMPENSATION INSURANCE CERTIFICATION <br />As required by California Labor Code Section 1860 and 1861, the Contractor certifies as follows: <br />I am aware of the provisions of Section 3700 of the Labor Code, which requires every employer to be <br />insured against liability for worker's compensation or to undertake self-insurance in accordance with the <br />provisions of the Code, and I will comply with such provisions before commencing the performance of <br />the work of this contract. <br />If I, as the Contractor, now or at any time during the course of this agreement, qualify as an employer <br />under California Labor Code Section 3300, unless the hired employee(s) is (are) persons excluded by <br />said Labor Code, I shall furnish the City of Santa Ana with an insurance certificate from my workers' <br />compensation insurance carrier certifying that I carry such insurance and that the policy shall not be <br />canceled nor the coverage reduced except upon thirty (30} days prior written notice to the City of Santa <br />Ana. __ <br />' ---~ <br />Signed ::~'~_._.~ =- ;~`"'" n__~_ ~-a.~l~ ~ ~~.~~~~~~~ <br />Title ~~~~ ~ ~gv~ <br />Firm C~1i~~~ ~~~J~ ~ RIG1 1i (~~~-Pct~y ~~~` . <br />Date !-~ ~ 2lD ' ~ l~ <br />• <br />TO BE INCLUDED IN BID PACKAGE <br />BP8of31 <br />