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CITY OFSANTAANA <br />Risk MANACEkENT s dw 4 HumAN REsomcEs �� y,•��', <br />Managing Risk wouT Postdw Change <br />WORKERS' COMPENSATION DECLARATION <br />I, ChiftSano hereby affirm under penalty of perjury, the <br />(Name/nrh) <br />following declaration: <br />I certify on behalf of Recreation passes that during the term <br />(Consukont/Company Name) <br />of my contract for Dance and yoga instruction 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: 10:3=19 <br />Print Name: aw" s" <br />Print Title: Dance and Yoga ku*tietot <br />Signature: <br />Telephone: 714-9135559 <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 37D6 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />VED & APPROVED <br />MANAgEMEM DlvisiON <br />19 2019 <br />M. IAMBERT <br />