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Angie <br />D i g ita 1 [y,,5jg.,n„gd <br />RISK 1 A' NTa divi �� A ESOURCE� � k <br />�/"� <br />� rt o sl r <br />Date: 2024,08,21 <br />Le'Ve(I E 15:24:26T1007'00' <br />I, TTI01Q RONY 2 hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of Ff kilo f-amif ez that during the term <br />(Consultant/Company Name) <br />of my contract for Chr\SU 1+dib h 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 />6-1 110 120Z`1 <br />Print Name: VY\d Q lZoan1TeZ, <br />Print Title: UM U I <br />OM <br />Signature: <br />Telephone: C114 i $6�o6g� <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />SHALLSUBJECTAN 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 Mgmtllnsurance Requirements�WC Declaration 08152019 <br />RiekM0PgnnmtDWM!0n <br />EVIE R&APPRO BY: <br />A+.g-:, &w44 <br />z® <br />Rlsk Management Speaaht <br />