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Angie Digital ly5jigngd 8"iv r <br /> a <br /> RISK I A GEMENT HUMA 'ESOURCES <br /> division o� <br /> Date: 2024.08.21 <br /> . .ENSATION vE.CLARATION <br /> 15 :24:26 -07'OO' <br /> I, fYICAQ Ramirez hereby affirm under penalty of perjury, the <br /> (Name/Title) <br /> following declaration: <br /> I certify on behalf of frldia V.amlret that during the term <br /> (Consultant/Company Name) <br /> of my contract for CbhSU 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 /> b� l10202`% <br /> Print Name: vr idl Q 2.00mire2 <br /> Print Title: con V howl. <br /> Signature: <br /> Telephone: C114) sb QGg(o <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 /> \ / <br /> l: Risk Mgmt\lnsurance Requirements`WC Declaration 08152019 Risk Managea1estDrzsan <br /> REVIEWED&APPROVED By: <br /> Risk M nagementSpecialist <br />