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CITY OF SANTA ANA <br /> Risk Management a division of Human Resources <br /> Managing Risl(through Awareness and Action - <br /> AFFIDAVIT OF EXEMPTION FOR.WORKERS' COMPENSATION INSURANCE <br /> __—_("Representative"),attest that I am an authorized <br /> (Name and Title orVcndor Representative) <br /> representative of W�,, , _ ("Company"),and <br /> (Consu tantlCompany Name) <br /> , <br /> possess the authority to legally bind Company. <br /> In my capacity as Representative of Company, [ represent and confirm the following,as relates to the <br /> agreement between Company and City of Santa Ana,agreement number N``z 6?,S- I 19 <br /> ("Agreement")to provide_ ,�.�p�,� ' �_�(��ck (�- ("Services"): <br /> (Sar ces to be provided udder agreementicpntraet) <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 proofof 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(toes 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 R-Illy liable for any and all damages. <br /> Signature <br /> Print Name <br /> 'Vide <br /> Contact{nfornmion,i.e.,Telephone Numberandlor Email Address <br /> WARNING: FAILURE'T0 SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFIJL, <br /> AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL,FINES UP TO <br /> ONE HUNDRED TI-IOUSANT 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 ATTORNWS PEES. <br /> Affidavit of Exemption far Workers'Compensation Insurance 11.12,2024 <br />