Laserfiche WebLink
WORKERS' COMPENSATION DECLARATION <br />I _Geraldine Valencia hereby affirm under penalty of perjury, the <br />(Name(ritle) <br />following declaration <br />I certify on behalf of_ Geraldine Valencia that during the term of my <br />(ComulmntCompany Name) <br />contract for _Leisure Class services with the City of Santa <br />Ana, 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 those provisions and provide proof of workers' compensation coverage. <br />DATE: I J II <br />Signed By: U; :' "i L�A <br />Name: Geraldine Valencia <br />Title: <br />Telephone: <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 ATTORNEY'S FEES. <br />?_ev\e ed`ay'. <br />A� <br />P� <br />