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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 /> 1, D_ dN&yj o w P T F ("Representative"),attest that I am an authorized <br /> t'Nante and Title of Vender Representati lvc) <br /> representative of U N6 W®'Iv K t ro ("Company"),and <br /> (ConsultanVCompany Name) <br /> possess the authority to legally bind Company. <br /> In 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 CIO NSA UL`s1 ON ("Services"): <br /> (Services to be provided under agreemeniticuntrtct) <br /> During the course and scope of Company's agreement with the City of Santa Ana,Company will <br /> I not employ any person in any manner so as to become subject to the workers'compensation laws <br /> j of California,and agree that if Company should become subject to the workers'compensation <br /> I 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 /> 1 <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 rendering the Agreement <br /> null and void and Company will be fully liable for any and all damages. <br /> �!a_n:,lafC nS14 <br /> Prntt Name <br /> uV�R <br /> Tide _ <br /> kimbOA0w.0n 10,3919 & t I b <br /> Contact Information,i.e.,Telephone Number and/or Email Address <br /> A <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(S 100,000).IN ADDITION TO THE COST OF <br /> COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> IN TEREST,AND ATTORNEY'S FEES. <br /> Affidavit of Exemption for Workers'Compensation Insurance <br /> 11.12.2034 <br /> .ram . <br />