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CITYOFSANTAANA <br />Ri$K MANAGEMENT d&&ea 4HUMAN RESOURCES <br />Managing Risk owsh Pos M Change <br />WORKERS' COMPENSATION DECLARATION <br />Trevor Yates <br />(Name/Title) <br />following declaration: <br />I certify on behalf of <br />hereby affirm under penalty of perjury, the <br />that during the term <br />(Consultant/Company Name) <br />of my contract for copier/Printing 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 />Ventura Business Systems, Inc <br />Date:4/10/2020 .1// <br />Print Name: Trevor Yates <br />Print Title: President <br />Signature: y,� <br />Telephone: 805-58 -3299 <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 />REVIEWED & APPROVED <br />By Risk MANAGEMENT DivisiON <br />150. 2020 <br />ANgiE AcEvedo <br />I: I Risk Mgm t\lnsuronce RequirementsJWC Declaration 08151019 <br />