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WORKERS’ COMPENSATION DECLARATION <br />City of Pleasanton <br />P.O. Box 520 <br />Pleasanton, CA 94566 <br />I have and will maintain a certificate of consent t o s elf-insure f or workers’ c ompensation, as <br />provided for by Section 3700 of the Labor code, for the performance of the work for the City of <br />Fairfield, its officers, officials, employees and volunteers. <br />I certify that in the performance of the work for the City of Pleasanton, its <br />officers, officials, employees and volunteers, I shall not employ any person in any manner <br />so as to become subject to the workers compensation laws of California, and agree that <br />if I should become subject lo the worker’s compensation provisions of Section 3700 of the <br />Labor code, I shall forthwith comply with those provisions and provide the City of <br />Pleasanton with a Certificate of Insurance. In addition, if at any time during the performance <br />of the work for the City I hire an employee from a temporary agency, I will immediately <br />notify and provide the City with a current worker’ compensation certificate from said <br />temporary agency. <br />I plan to hire employees using a temporary agency. <br />The name of the agency is ____________________________________________________. <br />I have attached a copy of the temporary agency’s workers compensation certificate. If at any time <br />during the performance of the work for the City, I decide to use some other temporary agency. I <br />will immediately notify the City, and provide the corresponding workers’ compensation certificate. <br />WARNING: FAILURE TO SECURE WORKERS’ COMPENSATION COVERAGE IS <br />UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND <br />CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION <br />TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION <br />3700 OF THE LABOR CODE, INTEREST, AND ATTORNEY’S FEES <br />Signature Company Name <br />Print Name Company Address <br />Job <br />Date <br />Estimated Time-Frame of Job <br />PhoneEmail <br />W. Jay Hill <br />Chaplin and Hill Investigative Services LLC <br />191 Oak Knoll Loop <br />Walnut Creek, CA 94596, USA <br />(925) 899-3448 <br />11/05/2024 <br />jay@chaplinandhill.com <br />Investigative Services <br />Docusign Envelope ID: 1B65D8BB-306F-4CEA-97D4-8D9BBCF94581