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CITY OF SANTA ANA <br />RISK MANAGEMENT. ddoletam 4 HUMAN RESOURCES <br />Managing Risk ftmp, Fasitive Change <br />WORKERS' COMPENSATION DECLARATION <br />I, 61L L c !•Sd.V 1i kx e, 'do-ef�*Iereby affirm under penalty of perjury, the <br />(Nam ide) <br />following declaration: <br />I certify on behalf of I�ivc� �/`>os rV1h' c C �IA'I6411es that durinv the term <br />/V (Consultant/CoWpany Name) <br />of my contract for Lr9Also l/iNo, 14«1,rs1mc, services with the City of Santa Ana, <br />(Type of s l�ovided� <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: <br />Print Name: <br />Print Title: fy-e cli <br />` <br />Y- p" <br />Signature: <br />Telephone: <br />71ti q?,z - g�a� <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 />I:IRisk Mgmtllnsurance Requirements) WC Decfarotion 09152019 <br />RENEWED R&pAPPROVSr ED R <br />F4MM1.G�f1 R. vj&4 d <br />Ruk Management Marys[ <br />