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CITYOPSANTAANA <br />RISK MANAGEMENT a d4w,, 4HUMAN RESOURCES <br />Wriaging RIAI: mrorr,a+ftgdw ehenp <br />WORKERS' COMPENSATION DECLARATION <br />I, effip=7 ;a \LAQ J? D hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of _ C9kAj Q P 104 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 3700ofthe Labor Code, I shall forthwith <br />comply with the provisions and provide proof of workers' compensation coverage <br />immediately, <br />D. <br />Title, <br />Telephone:Print <br />• r <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 />k0sk Mgmtllnsurance RequirementslWC Declaration 081520I9 <br />