PROOF OF INSURANCE (2018 - 2019) CLOSED CITY 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:
(_) I 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 EI 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 EI 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 EI Segundo, I will not
employ any person in any manner so as to become subject to the workers' compensation laws of California, and
agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must
immediately comply with those provisions or the agreement will automatically become void.
Signature of Applicant A� '��'� Date 12/08/2016
Agreement for: V 'MA"' *-LHS4hon
Dated:
Reviewed by:
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