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N-2018-182 <br />WORKERS' COMPENSATION DECLARATION <br />I _Monica Robles DBA Heart Centered Leadership Coachinga <br />and Consulting Group, <br />(Name/Title) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />Icertify on behalf of_ Monica Robles DBA Heart Centered coaching <br />and Consulting Group that during the term of my <br />(Consultant/Company Name) <br />contract for Training____ services with the City of Santa Ana, I <br />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 those provisions and provide proof of workers' compensation coverage, <br />DATE: _Aug.21".2018 <br />By: _Monica Robles DBA Heart <br />Centered Coaching and <br />Consulting Group <br />Name: _Monica Robles DBA Heart <br />1 Ih Centered Coaching and <br />Consulting Group <br />a) Title: `President___ <br />Telephone: (480) 518-5557 <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 TLIE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />