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I, <br />CITYOF SANTA ANA <br />RISK MANAGEMENT a d&,wr 4 HUMAN RESOURCES <br />Managing Risk avough Positive Change <br />WORKERS' COMPENSATION DECLARATION <br />Terembang Subandhi <br />(Nome/Title) <br />following declaration: <br />I certify on behalf of <br />of my contract for <br />hereby affirm under penalty of perjury, the <br />Terembang Subandhi <br />that during the term <br />(Consultont/Compony Nome) <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: 11 /13/2019 <br />Print Name: Terembang (Terry) Subandhi <br />Print Title: Badminton Instructor <br />Signature: 7;i . <br />Telephone: (714 6 7 77 7'337 <br />44'-` <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 />%ncMFNT DivisiON <br />142020 <br />M. LAMBERT <br />I:�Risk Mgmt1lnsurance Requirements�WC Declaration 09152019 <br />