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CITY OF SANTA ANA <br /> R15R MANAGEMENT a division of HUMAN RESOURCES <br /> NI'IncigIng Risk : ' ,•,.,:, Positive Ch'-Inge - o=., ; <br /> Affidavit of Exemption for Workers' Compensation Insurance <br /> hereby affirm under penalty of perjury, the <br /> (Name/Title) <br /> following declaration: <br /> I certify on behalf of R that during the term <br /> (Consultant/Company Name) <br /> of my contract for � 1��`'� �.����-�.`� 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. <br /> Date: "ZZ e� <br /> L� t t <br /> Print Name: ' - <br /> Print Title: <br /> AA-�-, <br /> Signature: <br /> Telephone: I i Yc/ 'r— 17 <br /> , <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 ADDITPON TO THE COST OF COMPENSATION, DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, <br /> RiekMmwgetnrtED[+�alrnt <br /> RE e&m&APPRovm 8 <br /> 6 <br /> 2o.. _ rYc r A Aset+44 <br /> Risk Management Speci Jt st <br /> (:\Risk Mgmt\lnsurance Requi rem ents\Affidavit of Exemption for Workers' Compensation Insurance 2021 <br />