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I, <br />CITYOF.SANTAANA <br />RISK MANAGEMENT a division of HUMAN RESOURCE5 <br />Managing Risk urrouab Post m Change <br />Affidavit of Exemption for Workers' Compensation Insurance <br />Franklin Haynes <br />(Name/Title) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of Franklin Haynes Marionettes that during the term <br />(Consultant/Company Name) <br />of my contract for marionette puppet shows 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: 2/20/24 <br />Print Name: Franklin Haynes <br />Print Title: Puppeteer <br />Signature: <br />Telephone: 800-687-5393 �—r-- <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 />iiEVIE &APP ckmo : <br />A,,JU <br />®' Risk Management Spedahst <br />I:\Risk Mgmt\Insurance <br />Insurance 2021 <br />