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CITY OF SANTA ANA <br />RISK MANAGEMENT a drsmeere q HUMAN RESOURCES <br />Managing Risk ovva-4n Posidve Change <br />WORKERS' COMPENSATION DECLARATION <br />I, JI heve -, Ar e(!-r -J kt,H hereby affirm under penalty of perjury, the <br />(Nome/Title) <br />following declaration: <br />I certify on behalf of .A% y reb-,- l A /-r, J-r that during the term <br />i (Consultont/Company Name) <br />of my contract for �&(f 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 />Date: /D I S Z 3 <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 ADDITIONAL TO THE COST OF COMPENSATION, DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />kl Risk Mgmt�lnsurance Requirements) WC Declaration 08152019 <br />1 <br />�. <br />Rick mw% mad Dms on <br />RENEWED 6 ARRRQJED 8r. <br />A+f, Aavula <br />® <br />Risk Managemen[SpedAist <br />