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WORKERS' COMPENSATION DECLARATION <br />I _Trevor Yates hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of _Ventura Business Systems that during the term <br />Of my (Consultant/Company Name) <br />contract for 5 years services with the City of Santa Ana, I will not <br />employ any person in any manner so as to become subject to the workers' compensation <br />laws of California, and agree that if I should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br />with those provisions and provide proof of workers' compensation coverage. <br />DATE: <br />M. <br />Name: Trevor Yates <br />Title: President <br />Telephone: 805-583-3299 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY' S FEES. <br />cF RAManagementDMsian <br />Jy/,'q REVIEWED & APPROVED BY.- <br />V"° <br />W-- PIR Risk fjanagement Analyst <br />