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A • 2v/ i - owl <br />EXEMPTION from WORKERS' COMPENSATION <br />To be exempt from worker's compensation, you must submit an affidavit, certifying that <br />you do not employ anyone in a manner that is subject to the workers' compensation laws <br />of California. (See Business and Professions Code Section 7125.) <br />For exemption from worker's compensation, please complete the requested information, <br />check the box, and sign the form. <br />SECTION 1 — BUSINESS NAME / SOLE PROPRIETER NAME AND ADDRESS <br />FULL BUSINESS NAME <br />T.R. Holliman and Associates, Inc. <br />BUSINESS MAILING ADDRESS <br />City State Zip <br />3543 Citrus Street <br />Highland CA 92346 <br />BUSINESS PHONE NUMBER <br />BUSINESS FAX NUMBER <br />BUSINESS E-MAIL ADDRESS <br />(909) 573-6802 <br />N/A <br />trholliman@gmail.com <br />SECTION 2 — CHECK BOX <br />ZI do not employ anyone in the manner subject to the workers' compensation laws of the State of <br />California. <br />I certify under penalty of perjury under the laws of the State of California that the information provided on this <br />exemption statement is true and accurate. I understand that upon employinganyone in a manner that is subject to <br />the worker's compensation laws of the State of California,the claim of exemption executed under this form will no <br />longer be valid. I also understand that, as soon as I employ anyone subject to the California's workers' <br />compensation laws, I must obtain a Certificate of Worker's Compensation Insurance, submit that certificate to The <br />Regents of the University of California within 90 days of its effective date, and continuously maintain the coverage <br />Date Signature of (Owner, Partner, or Officer) <br />April 2, 2018 <br />