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CITV OF SANTA ANA (V <br />Risk Management a division of Human Resources <br />Managing Risk through Awareness and Action <br />Affidavit of Exemption for Workers' Compensation Insurance <br />I, c2A16-A JINf n%/, �� GFo hereby affirm under penalty of perjury, the <br />(Name/Tlde) T <br />following declaration: <br />I certify on behalf off /L /� 8V,6-X -1 S1m A1h(-7W o1(K that during the term <br />(Consultant/Company Nome) <br />of my contract for ��f /L ITk614&X T7-SIA)6 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: 1n1-?11poe- <br />Print Name: DOIV " &IA)/ZA,4y� <br />Print Title: c <br />Signature:.-�. �; <br />Telephone- <br />7p7 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />SHALLSUBJECTAN EMPLOYERTO CRIMINAL PENALTIES AND CIVIL FINES UPTO 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 />Affidavit of Exemption for Workers' Compensation Insurance <br />