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I, <br />CITY OF SANTA ANA <br />RisK MANAGEMENT. d&,v 4HUMAN RESOURCES <br />nagingRisk nnwpoPosftWChange <br />WORKERS' COMPENSATION DECLARATION <br />Roxanne Zavala <br />(Name/Title) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of Roxanne Zavala <br />of my contract for <br />(Consultant/Company Name) <br />that during the term <br />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 3700 of the Labor Code, I shall forthwith <br />comply with the provisions and provide proof of workers' compensation coverage <br />immediately. <br />Date: 111.301, o 19 <br />Print Name: 1ROXfYtJNE Z,4ilA z.4. <br />Print Title: Recreation Class Holistic Instructor <br />Signature: <br />Telephone: 310 _ 901— 5�a2 <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 />& APPROVED <br />IGEMENT DivisiON <br />2020 <br />I:IRisk Mgmtjlnsuronce RequirementslWCDeclarotion 015m0 <br />