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CITY nr SysN,m Aim <br />w v_ <br />FPosK MANAGEMEN'ra d(isLsfoa 4HunnlaN Resouaclrs <br />S C\M� ���ptf' hereby affirm under penalty of perjury, the <br />(NomejTrtle) � <br />following declaration. <br />I certify on behalf of m Sbkr;cR-1� U—C, that during the term <br />(Consultant/Company Name) <br />of my contract for ._ 4r1r l r q• v 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 />Date: I-),-13 1�( <br />Print Name: ---- <br />Print Title: _iAaY`QX <br />Signature: <br />telephone: i11�2�it p �W <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 ADDITIONAL_ TO THE COST OF COMPENSATION, DAMAGES <br />AS PROVIDED FOR IN SECTION :3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />REVIEW D & APPROVED <br />By nRisk I "FM DIVISION <br />11 0 2019 <br />1:1R1skMgmt1lnsuronceRepuirementstWCDeclaratl071AMIAMBPRT <br />