Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />I Blanca Arctic hereby aftirni under penalty of perjury, the <br />(NameiTitle) <br />following declaration <br />I certify on behalf of <br />Blanca Arceo <br />that during the terra of my <br />(GO11SURant/Company Name) <br />contract for Recreation Clan-ses services with the City of Santa Ana, I will <br />not employ any person in any manner so as to become subject to the workers' <br />compensation laws of California, and agree that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />DATE: <br />j cq. o, l - c B y )azl�m <br />Name: Blanca Arced <br />Title Recreation Class Instructor <br />Telephone: 714 805-0592 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($1.00,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND A'ITORNEY'S FEES. <br />