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CITY OFSANTA ANA <br /> RISK MANAGEMENT a division of HUMAN RESOURCES <br /> Managing Risk m Posidve Chang* <br /> Affidavit of Exemption for Workers' Compensation Insurance <br /> I, Michael Raneses / Director hereby affirm under penalty of perjury, the <br /> following declaration: <br /> certify on behalf of Michael Raneses Administrative Hearings that during the term <br /> of my contract for Administrative Hearing services with the City of Santa Ana, I will <br /> 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 <br /> forthwith comply with the provisions and provide proof of workers' compensation <br /> coverage immediately. <br /> Date: February 14, 2025 <br /> Print Name: Michael Raneses <br /> Print Title: Director Signature: <br /> Telephone: 714.287.4999 <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 /> I:\Risk Mgmt\Insurance Requirements\Affidavit of Exemption for Workers'Compensation Insurance 2021 <br />