Laserfiche WebLink
CITY OF SANTA ANA <br /> Risk Management a dlvlsion o€Human Resources <br /> Managing Risk through Awareness and Action <br /> AFFIDAVIT OF EXEMPTION FOR WORKERS' COMPENSATION INSURANCE <br /> I RICHARD SERRATO <br /> ("Representative"),attest that I am an authorized <br /> (Name rind Tile of Vendor Representative) <br /> representative of Santa Ana Lawn Bowling Club ("Company"),and <br /> (Coasudtarn)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 Ann,agreement number Santa Ana, <br /> ("Agreement")to provide Lawn bowling training services ("Services"}: <br /> (Services to be provided under agrecnienticontract) <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 /> 01/22/2026 <br /> Signature Date <br /> Richard Serrato <br /> Print Name <br /> Certified Lawn Bowling coach <br /> richardserrato@yahoo.com <br /> Contact inrorniation,i.e.,'Telephone Number and/or 13maiI 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 />