PROOF OF INSURANCE (2023) CLOSEDCITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000),
IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES.
I affirm under penalty of perjury under the laws of California one of the following declarations:
(_) ( have and will maintain a certificate of consent of self -insure for workers' compensation, issued by the Director
of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement
with the City of El Segundo.
Policy No.
(+) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance
of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance
carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent
Phone #
() I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not
mploy any person in any manner so as to become subject to the workers' compensation laws of California, and
agree that, if I should become sub' t to the workers' compensation provisions of Labor Code § 3700 l must
/I 1,A)
Signature of A licant ' � e agreement will automatically become void. immediately comply with th p ovis` ns or the
Date
Print Name �4`
Agreement for. -
Dated (66%, vq,�73
1 1 1 f�z�l
,, sumnce A proval:
Reviewed by:
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