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WORKER'S COMPENSATION INSURANCE CERTIFICATION <br />Description of Contract: <br />City of Redlands <br />Facilities and Comtnunity Services Department <br />Senior Center Outdoor Dining Facilities Construction Project <br />Project No 03012022JN <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 liability to pay compensation by one or more insurers duly <br />authorized to write compensation insurance in this State <br />b By securing from the Director of Industrial Relations, a certificate of consent to self - <br />insure, either as an individual employer, or as one employer in a group of employers, <br />which may be given upon furnishing proof satisfactory to the Director of Industrial <br />Relations of ability to self -insure and to pay any compensation that may become due <br />to his or her employees. <br />CHECK ONE <br />VI I am aware of the provisions of Section 3700 of the Labor Code which requires every <br />employer to be insured against liability for Workers' Compensation or to undertake self-insurance <br />in 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 <br />Agreement. (Labor Code §1861) <br />[ affirm that at all times, in performing the work and activities required or permitted under <br />this Agreement, I shall not employ any person in any manner such that I become subject to the <br />workers' compensation laws of California. However, at any time, if I employ any person such that I <br />become subject to the workers' compensation laws of California, immediately I shall provide the <br />City with a certificate of consent to self -insure, or a certification of workers' compensation <br />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 -20 day of 0—iil rl e. , 2022. <br />(Contractor) <br />fie*.' - <br />Signature) <br />pY� �7f-I <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 />L:\ca\Agreements\Deark E&C Contract.PW 3 I FY21-0141.doc.jn <br />