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CITY OF SANTA ANA <br />RISK MANAGEMENT. d4,e, a 4 HUMAN RESOURCES <br />Managing Risk up-e yt) Posfdve Change <br />WORKERS' COMPENSATION DECLARATION <br />Luis Martinez, Counselor <br />(Name/Title) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of Luis Martinez <br />(Consultant/Company Name) <br />that during the term <br />of my contract for Mental Health Counseling 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: July 26, 2021 <br />Print Name: Luis Martinez <br />Print Title: Counselor <br />Signature: �17����...�....._ <br />Telephone: 714 469-4011 <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 ($100,00Q). 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:�RiskMgmt�1nsurnnceRepuiremenfsiWCDeclaration08152p1g s REmEWEoM& RREDBY. <br />� t = rl Enat•�:�e.c I <br />Rttk Winzgement Analyst <br />