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CITY OF SANTA ANA <br />RISK MANAGEMENT a division of HUMAN RESOURCES <br />Managing Risk &mqp r Positive Change <br />Affidavit of Exemption for Workers' Compensation Insurance <br />Michael Enriquez, owner hereby affirm under penalty of perjury, the <br />(Nome/Title) <br />following declaration: <br />I certify on behalf of SoCal Drum Party LLC that during the term <br />(Consultant/Company Name) <br />of my contract for Drum Circle 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: 2/26/24 <br />Print Name: Michael Enriquez <br />Print Title: Owner <br />Signature: 'U <br />Telephone: 626-715-1371 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />SHALL SUBJECTAN 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 />% <br />Rlele Mnriagemml DlWlan <br />Re it & APPR ED By., <br />�'® <br />Risk Management Specialist <br />