Laserfiche WebLink
CITYOFSANTAANA <br />RI5K MANAGEMENT a division of HUMAN RESOURCESn <br />Managing Rl* dvwptPosidw Change <br />Affidavit of Exemption for Workers' Compensation Insurance <br />Founder, Candace Thorne <br />(Name/Title) <br />following declaration: <br />I certify on behalf of Swim Brayv <br />hereby affirm under penalty of perjury, the <br />that during the term <br />(Consultant/Company Nome) <br />of my contract for Edutainment Presentation 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: 03/13/24 <br />Print Name: Candace Thome <br />Print Title: Exec Dir and founder <br />Signature: <br />Telephone: 70 2-9 69-9 678 <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 <br />9r� <br />Risk hknaMera:Dwislan <br />REVIEWED &APPROVEDBY: <br />°il,is}1I Ia 1: <br />Aq�. <br />Al "44 <br />" <br />Risk Manzgemen[SpeciBist <br />