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CITYOFSANTAANA <br />RISK MANAGEMENT. 4 HumAN RESOURCES <br />�A,1a. -r�tc�m� P7sic ... �r,., ,positive Chr nge <br />Affidavit of Exemption for Workers' Compensation Insurance <br />I, s��pyF l 4 geDz&i ele hereby affirm under penalty of perjury, the <br />(Namelritle) <br />following declaration: <br />I certify on behalf of 14 so�MoA/ S." r- that during the term <br />(Consultant/Company Name) <br />of my contract for, yFop,,'N &- „ EFA--ZcA services with the City of Santa Ana, <br />(Type ofservice 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: 7- %% `6�� '2- <br />Print Name: S rEP#, 4 /�, se).e z--/Mo// <br />Print Title: gay So<o AoAl <br />Signature: �. <br />Telephone: 3q5—g767 <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 ATTORNEYS FEES. <br />I:\Risk Mgmt\Insurance Requirements\ Affidavit of Exemption for Workers' Compensation Insurance 2 <br />..... RiekMvagnnmtDh&bn <br />e' REVEwED 6 APPRW® By. <br />Risk Management Analyst <br />i,'d <br />d6b b0'ZZ 8l qe-i <br />i,'d <br />d6b b0'ZZ 8l qe-i <br />