Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />I I SS4 kid/ hereby affirm under penalty of perjury, the <br />(Nanie Tidc) <br />following declaration: <br />I certify on behalf of that during the tern of my <br />(ConsultantiCompany Namo) <br />contract for Rbk) ALASS services with the 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 and provide proof of workers' compensation coverage. <br />DATE: 11— 8 ' 16 <br />IN <br />Nair <br />Title <br />Telephone: i t. 1. <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION 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 ATTORrNEY'S FEES. <br />e6 63y e <br />�eJas <br />P <br />