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CITYOFSANTAANA <br />RISK MANAGEMENT. da-� gHUMAN RESOURCES ?_ <br />tV 01-,, 01119P.isi< :: -0 Positive Change <br />WORKERS' COMPENSATION DECLARATION <br />Melina Herrera hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of Melina Herrera that during the term <br />(Consultant/Company Name) <br />of my contract for Recreation Glasses 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: 2 12— o 2,o <br />Print Name: Q-1k i�V(e!, l <br />Print Title: Recreation Class Instructor <br />Signature: <br />Telephone: L-7 V 5- 5— /172 <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 />gy RIEWlsk M� <br />l:IRisk Mgmt1insurance Requirements) WC Declaration 08152019 <br />I] <br />