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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 /> Flor m. Campos <br /> 1, ("Representative"), attest that I am an authorized <br /> (Name and Title of vendor Representative) <br /> representative of Flor M. Campos ("Company"),y"), and <br /> p <br /> (Consul tant(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 /> ("Agreement")to provide Adult Art Classes ("Services"): <br /> (Services to be provided under agreementicontract) <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 and void and Company will be fully liable for any and all damages. <br /> • 1 104/2026 <br /> Signature Dme <br /> Flor M. Campos <br /> Print Name <br /> Art Instructor <br /> _ I itic <br /> (714) 809-4893/ sipandpaintqueen@gmail.com <br /> Contact Information,i.e.,Telephone Number and/or Email address <br /> WARNING; FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, <br /> AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO <br /> ONE HUNDRED THOUSANT DOLLARS($100,000). IN ADDITION TO THE COST OF <br /> COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> INTEREST, AND ATTORNEY'S FEES_ <br /> Affidavit of Exemption for Workers'Compensation Insurance 11.12.2024 <br />