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CITY OF SANTA ANA <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, <br />ELIO PALACIOS JR <br />(Name and Title of Vendor Representative) <br />representative of <br />("Representative"), attest that I am an authorized <br />PALACIOS LAW OFFICE <br />(Consultant/Company Name) <br />possess the authority to legally bind Company. <br />("Company"), and <br />In my capacity as Representative of Company, I represent and confirm the following, as relates to the <br />agreement between Company and City of Santa Ana, agreement number <br />("Agreement") to provide <br />HEARING OFFICER SERVICES <br />(Services to be provided under agreement/contract) <br />("Services"): <br />During the course and scope of Company's agreement with the City of Santa Ana, Company will <br />not employ any person in any manner so as to become subject to the workers' compensation laws <br />of California, and agree that if Company should become subject to the workers' compensation <br />provisions of Section 3700 of the Labor Code, Company shall forthwith comply with the <br />provisions and provide proof of workers' compensation coverage immediately. <br />If at any time it is found that Company is not adhering to any and/or all of the statements in this <br />document and does not maintain the minimum professional liability insurance coverage as <br />required in the Agreement, it will be considered a breach of Agreement rendering the Agreement <br />null and void and Company will be fully liable for any and all damages. <br />Signature <br />ELIO PALACIOS JR <br />OWNER <br />Print Name <br />Title <br />ELIO@PALACIOSLAWOFFICE.COM <br />Contact Information, i.e., Telephone Number and/or Email Address <br />01/21/2025 <br />Date <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, <br />AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO <br />ONE HUNDRED THOUSANT DOLLARS ($100,000). IN ADDITION TO THE COST OF <br />COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br />INTEREST, AND ATTORNEY'S FEES. <br />Affidavit of Exemption for Workers' Compensation Insurance 11.12.2024 <br />