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CITYOFSANTAANA <br />RISK MANAGEMENT,a 4HUMAN RESOURCES <br />h9�ela.7r�fne�Itlsku�.c�il'tasJt�vetJasuat�e � =4 <br />WORKERS' COMPENSATION IDECLARATION <br />I' X" `Al OOANG hereby affirm under penalty of perjury, the <br />(Name/Ttle) <br />foiiowing deciaration: <br />I certify on behalf of KH,+l /foot 1G } )) tom} that during the term <br />(ConsultantlCompany Name) <br />of my contract for Repreation Classes services with the City of Sanica 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 ia%as 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 />comp4Y with the provisions and provide proof of workers' compensation, coverage <br />immediately. <br />Date: //// /1e2©19 <br />Print Name: <br />Print Title: <br />_ 4,,VCE .ZnIs��Ga�TD�2 <br />Telephone:-� <br />2- <br />�z-3s_ <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 15 UNLAWFUL, AND <br />Sr'A&Si,t�JTCT�SG'Eibhslu^i'ECiGu'K)IIAM")11A E3r�iG'u^�iV'i rtSG�S�r"iu^u1GLrti'i11ftDRED <br />THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMP-%GES AS <br />PROVIDER FOR, W SE_C-MON..3706OF T-H.E U480P C00F_, [NTF_RF_ST, AI\lD AT.TOR.NEY'S FEE,-;, <br />& APPROVED <br />QEMEW DIVISION <br />�7 2019 <br />M. LAMBERT <br />k1RIsk M9mtllnsuronce Requirements) WC Declaration 08IS2019 <br />