Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />1, Charlotte D. Whitney ,hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of StrategicSolutions_ that during the term of my <br />(Organization Name) <br />contract with the Facilities Fleet and Central Stores Division, City of Santa Ana, I will <br />not employ any person in any manner so as to become subject to the workers' <br />compensation laws of California, and agree that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith <br />comply with those provisions. <br />DATE:% <br />By: <br />Name: CN <br />Title: Pros <br />Telephone: <br />OS' <br />WARNING: FAILURE TO SECURE WORKERS' COMPENS11ON COVERAGE IS <br />UNLAWFUL, AND SHALL, SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />