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CITY OF SANTA ANA <br /> Risk Management a division of Human Resources <br /> Managing Risk through Awareness and Action <br /> AFFIDAVIT OF EXEMPTION FOR WORKERS' COMPENSATION INSURANCE <br /> me and Titfe of Vcndor R ("Representative"),attest that I am an authorized <br /> ePresentative) <br /> representative of \---' <br /> 11 ("Company"),and <br /> (ConsultantlCompany Name) <br /> Possess the authority to legally bind Company. <br /> It' MY capacity as Representative of Company,I represent and confirm the following,as relates to the <br /> agreement between Company and City of Santa Ana,agreement number <br /> ("Agreement")to provide s r% E S S <br /> (S 'cestobepmridedund_gU.rnent/eontraet} ("Services"): <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 /> 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 does not maintain the minimum professional liability insurance coverage as <br /> required in the Agreement,it will be considered a breach of Agreement rcr�dering the Agreement <br /> null and void and Company will be fully liable for any and all damages. <br /> Sigr»atury `�-- <br /> to <br /> `Paint Name _^ <br /> Tale <br /> o\vo 5--� cvU � Q� 1�•� Q� I �0m <br /> Caatact Information,i.e.,Telephone Number and/or Email Addrrsss <br /> 1NG: DAILURI TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL <br /> AN EMpLoYER TO CRIMINAL PENALTIES AND CIVIL FINES A L, <br /> W p�S14AI-L SU11JEOUSANT DOLLARS($100,000).IN ADDITION TO THE COST OF TO <br /> AND Ht jNDRED DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE L q$OR <br /> ONE ATIO ORNEy'S FEES. CODE, <br /> GG ST,AND <br /> FNTI R �pensatlon insuranm <br /> Affidavit of f ernPuan for Workers �1.1a.2o�a <br />