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CITY OF SANTA ANA 70' <br /> 114 <br /> Risk Management a division of Human Resources <br /> Managing Risk through Awareness and Action %��Jr�l <br /> AFFIDAVIT OF EXEMPTION FOR WORKERS' COMPENSATION INSURANCE <br /> I Madison Romero Alarcon <br /> ("Representative"), attest that I am all authorized <br /> {Name and Title of Vendor Representative) <br /> representative of Veritas AdVISUS ("Company"), and <br /> (Cunstdiant: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 TBD <br /> (-Agree In Consultingent")to provide (`:Services"): <br /> (Services to be provided under agreementfeontract) <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 workers' compensation 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 /> ' 06/27/25 <br /> Si nanicf a Date <br /> Madisson Romero Alarcon <br /> Print Name <br /> Coonsultant <br /> Title <br /> Contact Information.i e Telephone Number and/or Email Address <br /> WARUNING: FAILURE TO SECURE WORKERS* COMPENSATION COVERAGE IS UNLAWFUL, <br /> AND SHALL SUBJECT AN EMPLOYER TO CRItbINAL PENALTIES AND CIVIL FINES UP TO <br /> ONE HLTNDRED THOUSANT DOLLARS($100.000). LN ADDITION TO THE COST OF <br /> COMPENSATION.DAtiIAGES AS PROVIDED FOR IN SECTION 1706 OF THE LABOR CODE, <br /> INTEREST,AND ATTORNEY'S FEES. <br /> Affidavit of Exemption for Workers'Compensation Insurance 11,17.2024 <br />