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Risk Management a division of Human Resources Managing Risk through Awareness and Action Zo AFFIDAVIT OF EXEMPTION FOR WORKERS' COMPENSATION INSURANCE 1, D-QA0 �� VA () ("Representative"),attest that I am an authorized (Name and Title of Vendor Representative) representative of ("Company"),and (Consultant/Company Name) possess the authority to legally bind Company. In my capacity as Representative of Company,I represent and confirm the following,as relates to the agreement between Company and City of SantaAna,agreement number ("Agreement")to provide J`�y tr u.t-r4� , � �v��o. PC, A—Services"): (Services to be provided under agreement/contract) During the course and scope of Company's agreement with the City of Santa Ana,Company will not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if Company should become subject to the workers' compensation provisions of Section 3700 of the Labor Code,Company shall forthwith comply with the provisions and provide proof of workers' compensation coverage immediately. If at any time it is found that Company is not adhering to any and/or all of the statements in this document and does not maintain the minimum professional liability insurance coverage as required in the Agreement, it will be considered a breach of Agreement rendering the Agreement null and void and Company will be fully liable for any and all damages. Signature (�- Date Print Nam Title kJOA 'D 1� e qu,4cd-, Cont Informatsan,i.e.,Telephone Number andlor Email Address WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSANT DOLLARS($100,000). IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST,AND ATTORNEY'S FEES.