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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 /> 1,Zoo F A m4 enns i ' ,qxf ("Representative"),attest that I am an authorized <br /> (Name and Title of vendor Representative)representative of s UwAtow l C <br /> ("Company"),and <br /> (Consullant/Crnnpany Nome) <br /> possess the authority to legally bind Company, <br /> In nay capacity as Representative oi'Cotnpa.ny,I represent and confirm the following,as relates to the <br /> agreement between company and City of Santa Ana,agwonient number <br /> ("Agreement")to provide ("Services"): <br /> (Services to be provided under agt+eemcutleontrnct) <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 wormers' compensation laws <br /> of California,and agree that if Company should become subject 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 /> i <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 workers'compensation insurance coverage as <br /> required in the Agreement,it will he considered a breach of Agreement rendering the Agreement <br /> null and void and Company will be fujiy liable for atty and al.l damages. ! <br /> ignatar Date <br /> PrintNmne <br /> Title <br /> 13 x 70A-V 4A e H 6) -*.h A <br /> Cantaot infonnation,i.e.,Telephone Number and/or Ei it Addr ou <br /> WARNING: FAILURE TO SHCURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, <br /> AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO <br /> ONE IIUNDRED TI-IOUSAN`r nOLLARS($100,000),IN ADDITION TO THE COST OF i <br /> COMPENSATION,DAMAGES AS PROVIDED FOR 1N SECTION 3706 OF THE LABOR CODE, <br /> INTERR+ST,AND ATTORNEY'S FEES. <br /> i <br /> Affidavit of Exemption for Workers'Compensation Insurance 11 72.2024 <br /> i <br /> _ i <br />