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CITY OFSANTAANA <br />RISK MANAGEMENTa w44" 414umAN RESOURCES <br />Ma OOV Risk ftwollP Wft Change <br />WORKERS' COMPENSATION DECLARATION <br />l Estelle Sales Sarmlento,onbehalf ofSantiago Bautista hereby affirm under penalty of perjury, the <br />(Name%ritle) <br />following declaration: <br />I certify on behalf of Estella Salas Sarmiento, Santiago Bautista that during the term <br />of my contract for <br />(Consultant/Compony 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: Q z /O6 Iko <br />Print Name: E�/-d44 :5W&FvN i <br />Print Title: instructor <br />Signature: <br />Telephone: h Y2 � S 33 Id - <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 DMsioN <br />FE8 O�P020 <br />AN`giEE A'C'EVEdo <br />kj isk Mgmt1insurance Requlrementsl WC Declaration 08152019 <br />