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CITY OF SANTA ANA <br />RISK MANAGEMENT a dsvra<am 4 HUMAN RESOURCES <br />Managing Risk Positive Change <br />WORKERS' COMPENSATION DECLARATION <br />r� <br />I hereby affirm under penalty of perjury, the <br />(Name/7it1eJ <br />following declaration: <br />I certify on behalf of %I � � c�IKT�-.s that during the term <br />(Consultant/Cott pany Name) <br />of my contract forservices with the City of Santa Ana, <br />(Type of service provided) <br />I will 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 the provisions and provide proof of workers' compensation coverage <br />immediately. <br />D'*n' <br />Print Na <br />Print T <br />Signat <br />Telephc , <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED <br />THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />1:}Risk Mgmtllnsurance RequirementslWCDedaration 08152019 <br />RiskMmWmentDMsian <br />REVIEWED&APPROVED BY: <br />f�W� R. vd,44d <br />'� Risk Management Analyst <br />