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CITY OFSANTAANA — <br /> RISK MANAGEMENT.dar a.4HLM&N RESOURCES ; '4 k <br /> Managing Risk rftwo Positive Change 1 , <br /> WORKERS'COMPENSATION DECLARATION <br /> SE E / o01 E�2 <br /> hereby affirm under penalty of perjury, the <br /> (Name! ,toe) <br /> following declaration: <br /> I certify on behalf of Psz"'" f err 32R"`61 V" that during the term <br /> (Consuhant/Company Name) <br /> of my contract for RI,- 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: <br /> 8 ly-.ti`1 <br /> Print Name: <br /> V 'c 4a7e M,a,2-r,,.,EZ <br /> Print Title: QW„EQ <br /> Signature: --- <br /> Telephone: <br /> — '7Y3- 7830 <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 IRlsk Mgmtlinsurante Requf emeots I WC D&aradon 08152019 <br /> Riskr <br /> Management Division <br /> . ii ,� REVIEWED&APPROVED BY: <br /> ,tl11Id A AL444 <br /> Risk Management Specialist <br />