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CITY OF SANTA ANA <br />RISK MANAGEMENT, d4a4 s 4HUMAN REsoURCEs ; <br />Managing Risk araug*r Posittwe Change <br />WORKERS' COMPENSATION DECLARATION <br />1, Y Urnnc(y I V✓t-6 XWW v-✓ hereby affirm under penalty of perjury, the <br />(Nome/Title) <br />following declaration: <br />I certify on behalf of !i V that during the term <br />(Consultant/Company Name) <br />of my contract for S CA-h 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: 16 — 0 S- , -o x 0 <br />Print Name: <br />5Qru641 J0 JIGre-(� <br />Print Title: Dw y- <br />Signature: <br />Telephone: 72-6f-� 050 <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 />1:1 Risk MgmtVnsurance Requirements �WC Declaration 08152019 <br />weklnir�n . <br />REmEwED & Arraovm 8,r <br />�=�-' Ruk Managem nl Malys) <br />