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CITY OF SANTA ANA
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<br /> AFFIDAVIT OF EXEMPTION FOR WORKERS COMPENSATION INSURANCE
<br /> I Angela Shaw ("Representative"),attest that I authorized
<br /> Q,4 d"f"itle of Vendor o tartWe)
<br /> The ADR Coach Inc.
<br /> representative of.......................I ....... ,_, ......ConniftwWCompany..... ...,,,....,,............ ('Company"), d
<br /> (".................'.. )
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<br /> possess authority to legally bind Company.
<br /> In my capacity s Representative of Company,I represent and confirmthe following,as relates tot e
<br /> agreement Company and City of Santa Ana,agreement nu r A-2025-028-08
<br /> ("Agreement")to provide Hearing Officer ("Services"):
<br /> (Sewim to be proven t/ )
<br /> During the course and scope of Company's agreement wi e City of Santa Ana,Company will
<br /> not employ any personin 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 Section7 of the Labor Code,Company shall forthwith comply with the
<br /> provisions vie proof of workers' compensation coverage immediately.
<br /> If at any time it is found that Company is not adhering to any r all of the statements in this
<br /> document and does not maintain the minimum workers'compensation insurance coverage as
<br /> required in the Agreement, it will be considered r h of Agreement rendering the Agreement
<br /> null and void Company will be fully i le for any and all damages.
<br /> 08/07/2025
<br /> ..---...... _..._._ .m.......,,
<br /> s, . ..
<br /> Angela Shaw
<br /> ...,",,,,......... ,,,,,, ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,.,.,,,.,,,.,,,,,... .... _,,,,,,,,,,,................................. ,,,,,,,,��mm ... ,,,,,.,,,,,,.,,,._,..,,,�.._w. _,,,,,,,,,,......,,,,,,,,,,.,,,,,,,,,,,,.... ,......."...., ,,,,,............................
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<br /> Principal
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<br /> (323) 810-0626 and theadreoach@aol.com
<br /> CmIact Inforii ors,U..,Telephone Nundwr or E
<br /> WARNING: FAILURE TO SECURE E 'C E S T COVERAGE IS UNLAWFUL,
<br /> AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES TO
<br /> E HUNDRED THOUSANT DOLLARS($100,000).IN ADDITIONTO THE COST OF
<br /> COMPENSATION,DAMAGES AS PROVIDED FORSECTION 3706 OF THE LABOR CODE,
<br /> INTEREST,AN Y'S FEES.
<br /> Affidavit of Exemption forWorkers'Compensation Insurance 11.12.202
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