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CITYOFSANTAANA <br />RISK MANAGEMENT a &wa6ara 4 HUMAN RESOURCES " <br />Managing R1s1(#mwAPosfflva ClIange <br />WORKERS' COMPENSATION DECLARATION <br />it 4tgEVZN P, hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of H .solamoa✓ that during the term <br />'' (Consultant/Company Name) <br />of my contract for ' d � services with the City of Santa Ana, <br />(Type fservi 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: <br />Print Name: 15�/���/ <br />So.Cz,.y1o.+1 <br />Print Title: <br />S70 L f lJW A/Ar— /2 S�G'6�e <br />Signature: <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 ATTORNEY'S FEES. <br />kjRisk Mgmtklnsurance Requirements�WC Declaration 08152019 <br />Risk MwaganattDMsian <br />pr`REMEWED&{AP'�R <br />PIRIOeVVEDBY. <br />R. VNMK <br />�� Risk Management Analyst <br />