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CITY OF SANTA ANA�, <br />ISK ANAGEMENT��`d�ry�� Mamligfng i���anl�of�HUMRURCg,',,, <br />Affidavit of Exemption for Workers' Compensation Insurance <br />I, Michael Raneses / Director hereby affirm under penalty of perjury, the <br />following declaration: <br />certify on behalf of Michael Raneses Administrative Hearings that during the term <br />of my contract for Administrative Hearing services with the City of Santa Ana, I will <br />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 <br />forthwith comply with the provisions and provide proof of workers' compensation <br />coverage immediately. <br />Date: February 14, 2025 <br />Print Name: Michael Raneses <br />Print Title: Director Signature: <br />Telephone: 714.287.4999 <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:\Risk Mgmt\Insurance Requirements\ Affidavit of Exemption for Workers' Compensation Insurance 2021 <br />