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CITYO <br />ANA <br />..F I a <br />RisK <br />* * RuouRCES <br />Managing Risk ftwov <br />m k MrChange <br />hereby affirm under penalty of perjury, the <br />(NamelTt1'e) <br />following declaration: <br />I certify on behalf of A-- wV IoA1SI L(— " that during the term <br />(ConsultontlCompony Name) <br />of my contract for A/1111" services with the City of Santa Ana, <br />(Type of service provided) <br />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 became 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 />Cate: 1 <br />2-1 <br />Print Marne: , r �- <br />Print `title: E� <br />Signature: 14ma_ <br />i � � M � x '" • • � i • � r � IIY �yNIIM � � r � M � � r <br />i:\Risk M mt\Insura,nc Requirements' Affidavit of Exemption for workers' Compensation Insurance <br />�w a Kim i UUUq;Cme2a Umawn <br />3/ REVIEWED & APPROVm BY. <br />— —� Risk Management Analyst <br />