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CITYOFSANTAANA <br />RISK MANAGEMENT. Alw,ua.. e6 HU1AAN RESOURCES <br />Fd* owq* PosIM CharVe <br />WORKERS' COMPENSATION DECLARATION <br />Justin Unsworth on behalf of Santiago Bautista hereby affirm under penalty of perjury, the <br />(Namelritle) <br />following declaration: <br />I certify on behalf of Justin Unsworth on behalf of Santiago Bautista that during the term <br />of my contract for <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 />(Consultot;VCompany Name) <br />Recreation Classes services with the City of Santa Ana, <br />Date: 9 , (;� -0 <br />Print Name: -r v��� <br />�.J it 0 r-, Sy�c9 C' <br />Print Title: Recreation Class Martial Arts <br />Signature: \ j Vlys�JaiY- kh <br />Telephone: i% 141 ; -Z2 - O `rSO Fz, <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 />FEB 1,0.2020 <br />ANC{iE ACEVEdo <br />I:IRIsk Mgmtllnsuronce Requirementsl WC Declaration 08152019 <br />