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C77T OF SAN7A ANA <br />_m <br />RISK MANAGEMENT. dea,4l n 4 HUMAN RESOURCES <br />Managing Risk auorrgb Positive Change <br />WORKERS' COMPENSATION DECLARATION <br />I, �L LLALQ C�) g `a 0 � 0 hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of Silvia Salgado that during the term <br />(ConsultantJCompany Name) <br />of my contract for <br />Recreation Classes <br />(Type of service provided) <br />services with the City of Santa Ana, <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 2-- l 3— t! <br />Print Name: S lU 1 C4 CA` 0 C10 <br />Print Title: <br />S�yUSLJnY <br />Signature: <br />Telephone: <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 />REVI ED & APPROVED <br />Y Ri MANAGEMENT DwisiON <br />J N14"cO8 <br />5440141 M 44 1 AMRERT <br />1:\Rlsk Mgmtjlnsurance Requirements)WC Declaration 08152019 <br />