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Q <br />CITY OFSANTAANA <br />RI MANAGEMENT HUMAN RESOURCES <br />SK a &,,, aaoa 4 <br />Managing Risk through Posture Change <br />t <br />WORKERS' COMPENSATION DECLARATION ✓ <br />Raquel Gutierrez <br />(Namelritle) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of Raquel Gutierrez <br />of my contract for <br />that during the term <br />(Consultont/Company 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: 1 /31 /2020 <br />Print Name: Raquel Gutierrez <br />Print Title: Recreation Instructor <br />Signature: r i� <br />Telephone: <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 ATTORNEYS FEES. <br />REVIEWED & APPROVED <br />By Risk MAnagoMEw DMsioN <br />W 41020 <br />l:l Risk Mgmtllnsuronce Requirementst WC Declaration 09152019 <br />