Laserfiche WebLink
CITY OF SANTA ANA <br />R15K MANAGEMENT a d4wt 4 HUMAN RESOURCES <br />Managing Risk nscrgvl Posltive Change <br />WORKERS' COMPENSATION DECLARATION <br />l Santiago Bautista <br />(Nome/Title) <br />following declaration: <br />C <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of Santiago Bautista <br />of my contract for <br />that during the term <br />(Consultant/Company Name) <br />Recreation classes services 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 />Date: zZs z <br />Print Name: S c1h446 t % fsny-6� <br />Print Title: Recreation Class Martial Arts <br />Signature: <br />Telephone: y , Z 6' S <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 />REVIEWED D & APPROVED <br />o <br />PPROVED <br />BRisk <br />FEtp <br />20 <br />ANriE ACEVEdo T <br />PIRisk Mgmtllnsurance Requirementsl WC Declaration 08152019 <br />