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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 /> Kyo u t1 g I rl1 Kw0 n V G- Q>'1 ( `Representative"),attest that lam an authorized <br /> (N'mme and Title of Vendor Represenwivc) <br /> representative of Kyou ng I m Kw©n dba J H E I ("Company"), and <br /> (Consultant Company 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 /> i <br /> i ('*Agreement")to provide Golf Instruction ("Services")-. <br /> (Services to be prnvidal undLT agmnrien Vcon tract) <br /> During the course raid 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 covera,ge immediately. <br /> if at an% time it is found that Company is not adhering to any and/or Al of the statements in this <br /> document and does not maintain the minimum professional liability insurance coverage;as <br /> required in the Agreement, it Gill 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 /> �1/14/ _.6 <br /> Si�tan�re Date <br /> l 0 V t'iA'o Y�► G` oV- <br /> _ f rl Print Name <br /> Title <br /> Contact lnfonnation,i.e.Telophotic Number and or Email Address <br /> WARNING: FAILURE TO SECURE WORKERS' COtNIPENSATION COVERAGE IS UNLAWFUL, <br /> AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO <br /> ONE HUNDRED THOUSANT DOLLARS($100,000) IN ADDITION TO THE COST OF <br /> COMPENSATION, DAMAGES AS PROVIDED FOR 1N SECTION 3706 OF THE LABOR CODE, <br /> INTEREST,AND ATTORNEiY'S FEES. <br /> Affidavit of Exe1+1lat1cn for workem,Compensation Insurance 11.12 2024 <br />