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CITY OF SANTA ANA <br />RISK MANAGEMENTa dtwacaa 4HUMAN RESOURCES <br />Managing Rlsk mmag* Posttive Change <br />WORKERS' COMPENSATION DECLARATION <br />Trevor Yates <br />(Nome/Title) <br />following declaration: <br />I certify on behalf of <br />hereby affirm under penalty of perjury, the <br />Ventura Business Systems, Inc <br />that during the term <br />(Consultant/Company Name) <br />of my contract for Copier/Printing services with the City of Santa Ana, <br />(Type of service provided) <br />I will 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 the provisions and provide proof of workers' compensation coverage <br />immediately. <br />Date:4/10/2020 <br />Print Name: Trevor Yates <br />Print Title: President <br />Signature: �uuez <br />Telephone: 805-58 -3299 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED <br />THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />REVIEWED & APPROVED <br />By RISK MANAGEMENT DIVISION <br />15P 2020 <br />ANgiE ACEVEdo <br />kl Risk Mgmtllnsurance Requirements�WC Declaration 08151019 <br />