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I <br />bwls <br />OTY aF SANTA ANA <br />RISK MANAGEMENT, deew:a.:au „HUMAN RESOURCES . <br />l'(v-:;tltktx- C k1l)t1t, ' f, <br />WORKERS' COMPENSATION DECLARATION <br />oavo12I3pr "a b-'g"t"..'�iereby affirm under penalty of perjury, the <br />(Name/Title) <br />foi'lowing declaration: <br />I certify on behalf of eejoV C�WfieftL- w &_f that during the term <br />(ConsultantlCompany Name) <br />of my contract for DJ 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: N1 j q / %Z I <br />Print Name: t !S 4-✓ A <br />Print Title: 'sI n�c - r f'+�- %�Z m�'YL <br />Signature: c <br />Telephone: 01 G, _ <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:Risk Mgmtjlnsurance Requirements S WC Declaration 08152019 <br />Risk Management DMskm <br />e REVIEwm & APPROVED 8Y: <br />A+.�:= Acevado <br />'� Risk Management Spedafist <br />