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CITY OF SANTA ANA <br />RISK MANAGEMENTa &Pa4srr gHUMAN RESOURCES <br />Managing Risk erugh PosftW Change <br />WORKERS' COMPENSATION DECLARATION <br />I,1JiL,C- /VE�SaN/��ec �1i"ecL. hereby affirm under penalty of perjury, the <br />(Nome itle) <br />following declaration: <br />I certify on behalf of ;C�GS fA.),U/z1U4 C/n�riv� �� that during the term <br />(Consultant/Co any Name) <br />of my contract for n� ��u nlc✓snvc'ss�,s services with the City of Santa Ana, <br />yp f 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: G a e9 A 0 <br />Print Name:/30A/ <br />Print Title: <br />Signature: <br />Telephone: q?a _ g 3)y <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />SHALL SUBJECT AN EMPLOYERTO 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 ATfORNEY'S FEES, <br />REVIEWED & APPROVED <br />By Risk MANACEMENT DIVISION <br />J 9 2020 <br />ANGIE ACEVEdo <br />k: RiskMgmt1lnsuranceRequirements IWCDeclaration 08152019 <br />