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CITY OF SANTA ANA <br /> R15R MANAGEMENT a division of HUMAN RESOURCES <br /> Managing Risk nrtX0 POS"Change <br /> Affidavit of Exemption for Workers'Compensation Insurance <br /> \ay wl hereby affirm under penalty of perjury,the <br /> (Nomelritle) <br /> following declaration: \� <br /> I certify on behalf of C � `� S PV��O. `�� that during the term <br /> tonsultant/comgny Nome) <br /> of my contract for X(>,T ��r- �. 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. n �1 <br /> Date: <br /> Print Name: p AT A V�'�E <br /> Print Title: v'\�`l�`f 5� j uk13 <br /> Signature: <br /> Telephone: <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 /> APPROVED <br /> By Cynthia Mora at 3:28 pm, Dec 03, 2024 <br /> 1:\Risk M vnt\Insurance Requirements\Affidavit of Exemption for Workers'compensation insurance 2021 <br />