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WORKER'S COMPENSATION INSURANCE CERTIFICATION <br />Description of Contract State Street Trench/Conduit Installation — QOL05242018KG <br />Every employer, except the State, shall secure the payment of compensation in one or more of the <br />following ways <br />a By being insured against Iiability to pay compensation by one <br />or more insurers duly authorized to write compensation insurance in this State <br />b By securing from the Directoi of Industrial Relations, a <br />certificate of consent to self -insure, either as an individual employer, or as one <br />employer in a group of employers, which may be given upon furnishing proof <br />satisfactory to the Director of Industrial Relations of ability to self -insure and to pay <br />any compensation that may become due to his or her employees <br />CHECK ONE <br />I am aware of the provisions of Section 3700 of the Labor Code which requires every employer <br />to be insured against liability for Workers' Compensation or to undertake self-insurance in <br />accordance with the provisions of that Code, and I will comply with such provisions before <br />commencing the performance of the work and activities required or permitted under this Agreement <br />(Labor Code § 1861) <br />I affirm that at all times, in performing the work and activities required or permitted under this <br />Agreement, I shall not employ any person in any manner such that I become subject to the workers' <br />compensation laws of California However, at any time, if I employ any person such that I become <br />subject to the workers' compensation laws of California, immediately I shall provide the City with a <br />certificate of consent to self -insure, or a certification of workers' compensation insurance <br />I certify under penalty of perjury under the laws of the State of California that the information and <br />representations made in this certificate are true and correct <br />Dated this / D 7r/day of /tit , 2018 <br />(Contractor) <br />(Signature) <br />(Official Title) <br />(SEAL) <br />(Labor Code Section 1861 provides that the above certificate must be signed and filed by the Contractor with the <br />Owner prior to performing the work of the contract ) <br />4 <br />I 1ca1dJmlAgreementslHenkels & McCoy Public Works Contract docx <br />