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CITY OF SANTA ANA <br />RISK MANAGEMENT a &vae" ad HUMAN RESOURCES <br />Marmong BWc ow4le II Manse <br />WORKERS' COMPENSATION DECLARATION <br />Mario Rivera on behalf of Santiago Bautista hereby affirm under penalty of perjury, the <br />(Nome/Title) <br />following declaration: <br />I certify on behalf of Mario Rivera on behalf of Santiago Bautista that during the term <br />of my contract for <br />(ConsultonVCompany 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: O 0 /� <br />Print Name: //�� <br />VV(aPr'0 EUPVYh <br />Print Title: Recreation Class Martial Arts <br />Signature: <br />Telephone: / 9 l q + 06 <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 & APPROVED <br />By Risk MANAGEMENT DIVISION <br />F 020 <br />ANC{iE ACEVEdo <br />I:IRisk Mgmtllnsurance RequirementslWC Declaration 08152019 <br />