TWIST AND SHOUT EVENTS, INC. (3)

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CITY OF SANTA ANA Risk Management a division of Human Resources Managing Risk through Awareness and Action AFFIDAVIT OF EXEMP110N k-( )R WoRKERS' COMPENSATION INSURANCE 1, A ("Representative"),attest that I am an authorized G me and Title of V t or Rcpreseatativc) 1 representative of ("Company"), and (C:onsultanuC'umpany Name) possess the authority to legally bind Company. In my capacity as Representative of Company, I represent and confirm the following,as relates to the agreement between Company and City of Santa Ana, agreement number kJ A- ("Agreement")to provide I fn^ A)11�iho (.`Services"): (Service t be provided under agm6fritleonmico During the course and scope of Company's agreement with the City of Santa Ana, Company will not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if Company should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, Company shall forthwith comply with the provisions and provide proof of workers' compensation coverage immediately. If at any time it is found that Company is not adhering to any and/or all of the statements in this document and does not maintain the minimum professional liability insurance coverage as required in the Agreement, it will be considered a breach of Agreement rendering the Agreement null an id and Company be fully liable for any and all damages. Si to 'e Date � l Print Name Title 5 3:7 i�or1 h'yuI C Contac lnfartnation,i.c.,Telep one Number undlor Email Address l WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSANT DOLLARS(S I00,000). IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, fNTEREST,AND ATTORINEY'S FEES. Affidavit of Exemption for Workers'Compensation Insurance 11.12.2024