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WORKERS' COMPENSATION DECLARATION <br />I Flor Hemandez (Instructor) hereby affirm under penalty of perjury, the <br />(NamettiUe) <br />following declaration <br />I certify on behalf of Flor Hernandez that during the term of my <br />(Consultant/Company Name) <br />contract for Aerobics services with the City of Santa Ana, 1 will not employ any person <br />in any manner so as to become subject to the workers' compensation laws of California, <br />and agree that if I should become subject to the workers' compensation provisions of <br />Section 3700 of the Labor Code, I shall forthwith comply with those provisions and <br />provide proof of workers' compensation coverage, <br />DATE: January 4, 2019 <br />By: <br />Name: Flor Hernandez <br />Title: Instructor <br />Telephone: 714-277-6477 or 949-743-4396 <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 />A <br />