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CITY OF SANTA ANA <br /> Risk Management a division of Human Resources <br /> S '•'c f <br /> Managing Rlsk through Awareness and Action <br /> y. <br /> AFFIDAVIT OF EXEMPTION FOR WORKERS' CON1 IT NSATIOIN INSURAIN (.T <br /> ,,-Raul Martinez _ _("Rcpresentative") attest that f am an .rmhr,rizcxi <br /> (Name and Title of Vendor Representative) <br /> Raul Tl Qiablito" Martinez <br /> representative of ("('ornpanv"), and <br /> (Consultant/Company Name) <br /> possess the authority to legally bind Company, <br /> In my capacity as Representative of Company, I represent and confirm the following, as relates to the <br /> agreement between Company and City of Santa Ana,agreement number <br /> _ <br /> ("Agreement")to providemaster of ceremonies <br /> —(Services to be provided under agreeinenucontract) <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 workers' 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 /> 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 professional liability insurance coverage as <br /> required in the Agreement, it will be considered a breach of Agreement rendering the Agreement <br /> null a and Company will be fully liable for any and all damages. <br /> 9f5f25 <br /> �._ Signature . .. Data <br /> Raul Martinezt �- <br /> _____ Print itinme <br /> self-employed <br /> 'Title -' <br /> 818-325-6727 <br /> — —�Contact Information,i-e„Telephone Number andlor Email Address <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERACI IS UNL.AWFUL, <br /> AND SHALL SUBJECT AN EMPLOYER TO C111�1�LINAL PENALTIES AND CIVIL FINES UP 10 <br /> ONE HUNDRED THOUSANT DOLLARS($100,000), IN ADD(TION'1TO TI IE COST OF <br /> COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> INTEREST,AND ATTORNEY'S FEES. <br /> I <br /> Affldavit of Exemption for Workers'Compensation Insurance 11.12.2Q.1 <br /> — - I <br /> I <br />