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CITY OF SANTA ANA <br />Risk Management a division of Human Resources <br />Managing Risk through Awareness and Action <br /> <br />AFFIDAVIT OF EXEMPTION FOR WORKERS’ COMPENSATION INSURANCE <br />Gmps!n/!Dbnqpt <br />I, ________________________________________ (“Representative”), attest that I am an authorized <br /> (Name and Title of Vendor Representative) <br /> <br />Gmps!N/!Dbnqpt <br />representative of __________________________________________________ (“Company”), and <br /> (Consultant/Company Name) <br />possess the authority to legally bind Company. <br /> <br />In my capacity as Representative of Company, I represent and confirm the following, as relates to the <br /> <br />agreement between Company and City of Santa Ana, agreement number ____________________ <br /> <br />Bevmu!Bsu!Dmbttft! <br />(“Agreement”) to provide ____________________________________________________ (“Services”): <br /> (Services to be provided under agreement/contract) <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 /> <br />If at any time it is found that Company is not adhering to any and/or all of the statements in this <br /> <br />document and does not maintain the minimum professional liability insurance coverage as <br /> <br />required in the Agreement, it will be considered a breach of Agreement rendering the Agreement <br /> <br />null and void and Company will be fully liable for any and all damages. <br /> <br /> <br /> <br />201503137 <br />__________________________________________________________ ___________________ <br /> Signature Date <br />Gmps!N/!Dbnqpt <br />______________________________________________________________________________ <br /> Print Name <br />Bsu!Jotusvdups! <br />______________________________________________________________________________ <br />Title <br />)825*!91:.59:40!tjqboeqbjourvffoAhnbjm/dpn <br />______________________________________________________________________________ <br /> Contact Information, i.e., Telephone Number and/or Email Address <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 /> <br />