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CITY OF SANTA ANA <br />RISK MANAGEMENT, 4 HUMAN RESOURCES <br />Aftinaging f <br />WORKERS' COMPENSATION DECLARATION <br />_ I, s e, ,/ 6,,no,4/ hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />certify on behalf of zTzflY" /I s'ol-amo4l _ that during the term <br />(Consultant/Company Name) <br />of my contract for wAz services with the City of Santa Ana, <br />(Type(lf servi provided) <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 the provisions and provide proof of workers' compensation coverage <br />immediately. <br />Date: �, I <br />Print Name: <br />Print Title: <br />Signature: <br />Telephone: <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 Mgmtklnsurance Requirements ti WC Declaration 08152019 <br />flRlsk Mwwg=w1 DMslon <br />REVIEWED & NPROVED BY. <br />i <br />-.----� Risk ManagementAnalyV <br />