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CITY OF SANTA ANA <br />RISK MANAGEMENT a Ainw " 4HUMAN RESOURCES <br />Managing Risk nh,rwvn Posrdve Change <br />WORKERS' COMPENSATION DECLARATION <br />Ay `C \,��\ hereby affirm under penalty of perjury, the <br />(Nome17-1t1e) <br />following declaration: <br />I certify on behalf of C \,\� �V— ) �\ \ �\ �\C,\ that during the term <br />(Consultant/Company Name) <br />of my contract for 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: \\ 1 <� I \1\ <br />Print Name: \`\ <br />Print Title: V C�*,x, C�\ <br />Signature: <br />Telephone: (— `,- (\ \ , Or11,O <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 & APPROVEL <br />By Risk MANAGEMENT DIVISION <br />FEB 0 <br />rW1/L. <br />l: RiskMgmtklnsumnceRequirements�WCDeclaration <br />