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CITY OF SANTA ANA <br />PROJECT NO. 08 -1700, 12 -6421 AND 12 -6422 <br />PROPOSAL AND CONTRACT AGREEMENT <br />WORKERS' COMPENSATION INSURANCE CERTIFICATION <br />As required by California Labor Code Section 1860 and 1861, the Contractor certifies as follows: <br />I am aware of the provisions of Section 3700 of the Labor Code, which requires every employer to <br />be insured against liability for worker's compensation or to undertake self - insurance in accordance <br />with the provisions of the Code, and I will comply with such provisions before commencing the <br />performance of the work of this contract. <br />If I, as the Contractor, now or at any time during the course of this agreement, qualify as an <br />employer under California Labor Code Section 3300, unless the hired employees) is (are) persons <br />excluded by said Labor Code, I shall furnish the City of Santa Ana with an insurance certificate <br />from my workers' compensation insurance carrier certifying that I carry such insurance and that the <br />policy shall not be canceled nor the coverage reduced except upon thirty (30) days prior written <br />notice to the City of Santa Ana. <br />Signe ������ ,�_ { /�yJ <br />m t '� rzidl,e y <br />Title � i C t Pf�SI c��VYf- <br />Firm .�i11 Av►nPVI nnr� At�,ln.y1..1- <br />I� . - I ilk ..s. __ � , <br />TO BE INCLUDED IN BID PACKAGE <br />BP 14 of 20 <br />