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CITY OF SANTA ANA <br />RISK MANAGEMENT daa4m 411uMAN IlEsouRcls <br />Managing Risk ormpy Foattive Charge <br />WORKERS' COMPENSATION DECLARATION <br />I, JAY Utinc(� Vcl ��la Xw� v-✓ hereby affirm under penalty of perjury, the <br />(Name/7itle) <br />following declaration: <br />I certify on behalf of XV that during the term <br />(Consultant/Company Name) <br />of my contract for -C7" 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: 16 — O S- .Zo x d <br />Print Name: ,St <br />Print Title: ©� ✓ <br />Signature: <br />Telephone:7�y_ <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.IRisk Mgmtllnsuronce RequirementslWCOeclarotion 08151019 <br />IRintwm6MIMWIDBr ,: <br />RizkMaruge�rtrn Oei�cilNtle p <br />