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CITY OF SANTA ANA <br />RISK MANAGEMENT dcuea 4HUMAN RESOURCES <br />Managing RNk mxvo PosltNre Change <br />WORKERS' COMPENSATION DECLARATION <br />I, MyC , /41Q z hereby affirm under penalty of perjury, the <br />(Name tie) <br />following declaration: <br />I certify on behalf of <br />Fin k f, 143 -:Z., <br />that during the term <br />(Consultant/Company Name) <br />of my contract for O .7', 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: f-o/ 7 /7-2� <br />Print Name: <br />Print Title: <br />Signature: <br />Telephone: <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 NVmtllnsurance RequirementslWC Declaration 08152019 <br />tiEv1EWEo&APRRovEo BY: <br />T4ACy J" <br />Risk ManaQMen[ Maysi <br />