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CrrrOFSAxTA ANA <br />RISK MANAGEMENT, &,ew s 4 HUMAN REsomm <br />ManagN Rkk oftm t Pcs tllle Change <br />; <br />WORKERS' COMPENSATION DECLARATION <br />1, ,JPrVAnc o Vr�� ��- �tyv-✓ hereby affirm under penalty of perjury, the <br />(Nome/Title) <br />following declaration: <br />certify on behalf of V ,S that during the term <br />(Consultant/Company Name) <br />of my contract for 2T 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: 16 — D S- 2-c 2- O <br />Print Name: <br />Servcv�do UA��(c� <br />Print Title: oww Y- <br />Signature: /1 / <br />Telephone: 71'1— <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 />l:I iskMgmtkinsuronceRequfrementSlWCDed0ratiOn08152019 <br />Risk Mu agzment Division <br />REVIEWED & APPROVED BY. <br />3' <br />® Risk Management Analyst <br />