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WORKERS' COMPENSATION DECLARATION <br />I Hiba Shublak, Executive Director hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration <br />I certify on behalf of Active Learning, Inc, that during the term of my <br />(Consultant/Company Name) <br />contract for 2017 services with the City of Santa Ana, I will not employ any person in <br />any manner so as to become subject to the workers' compensation laws of California, and <br />agree that if I should become subject to the workers' compensation provisions of Section <br />3700 of the Labor Code, I shall forthwith comply with those provisions and provide proof <br />of workers' compensation coverage. <br />DATE: 12/20/16 <br />By: Active Learning, Inc. <br />Name: Hiba Shublak 1*r a Sh"Nak <br />Title Executive Director <br />Telephone: 714.717.4534 <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 ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />Reviewed by: <br />5,16 <br />Silvia Cuevas <br />PRf,,SA/Admin. <br />