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Angie <br />Acev <br />Digitally signed <br />ang RAana P I e <br />-D-ate�T -1Tb- ' _ <br />uv1 <br />'N'JRKERS' CO <br />:41 <br />FION D <br />7100, <br />RATION <br />I, h°c�A,=, 5.�� ,,l C tca hereby affirm under penalty of perjury, the <br />(Nome/title) <br />following declaration: <br />I certify on behalf of l-:c� ,), 'QQ0"CI that during the term <br />(Consultant/Company Name) <br />of my contract for A-,c e 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 <br />forthwith comply with the provisions and provide proof of workers' compensation <br />coverage immediately. <br />Date: <br />Print Name: <br />Cu'l CA <br />Print Title: t\ <br />C O�Jy,C •� /'f •GG <br />Signature: %} <br />Telephone: "j ty _ yg}_ —420tp <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 />l:l Risk Mgmtllnsuronce Requirements) WC Declaration 08152019 <br />RiskMUagmtmtDMs[m <br />RenE &APPRav®BV: <br />�' <br />Rdk Management Speaalist <br />