Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />I _Marisca M. Secundo hereby affirm tinder penalty of perjury, the <br />(Name'Tlde) <br />following declaration: <br />I certify on behalf of Marisca M. Sectmdo that during the term of my <br />(crosultsnbcampany Name) <br />contract for — Recreation Classes _ services with the City of Santa Ana, I will not <br />employ any person in any manner so as to become subject to the workers' compensation <br />laws of California, and agree that if I should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br />with those provisions and provide prorrof of workers' compensation coverage. <br />DATE: 3-20-17 <br />Signed By:_ <br />Name: Marisca M. Secundo <br />Title: Dance Instructor <br />Telephone: 714-781- <br />4017 <br />c <br />�e i/P _tea <br />WARNING: FAILUREEJr VORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND S LSU JECT AN EMPLOYER TO CRIMINAL PENALTIES <br />