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CITY OF SANTA ANA <br />RISKMANAGEMENT adi�4HUMAN RESOURCES <br />r, Postbae Change <br />D <br />WORKERS' COMPENSATION DECLARATION <br />Henry Morgenstern <br />(Name/Title) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of Security Solutions International Inc that during the term <br />(Consultant/Company Name) <br />of my contract for Training and Exercises 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: 12/28/2020 <br />Print Name: Henry Morgenstern <br />Print Title: P sid nt <br />Signature: <br />Telephone: 305-40 -6906 <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 />l: Risk Mgmt�lnsuranceRequirements�WCDeclaration08152019 <br />RmAwm & APPRavm By: <br />;ilYYAl:tIi1G�'� F,11 n.t l;, W41,4.1 <br />Risk Management Analyst <br />