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EXHIBIT "A" <br />WORKERS' COMPENSATION INSURANCE CERTIFICATION <br />Every employer, except the State, shall secure the payment of compensation in one or more of the <br />following ways: <br />(a) <br />(b) <br />By being insured against liability to pay compensation by one or more insurers duly <br />authorized to write compensation insurance in this State. <br />By securing from the Director of :Industrial Relations, a certificate of consent to <br />self -insure, either as an individual employer, or as one employer in a group of <br />employers, which may be given upon furnishing proof satisfactory to the Director <br />of Industrial Relations of ability to self -insure and to pay any compensation that <br />may become due to his or her employees. <br />CHECK ONE <br />R I am aware of the provisions of Section 3700 of the Labor Code which requires every <br />nployer 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 />. ffirm that at all times, in performing the work and activities required or permitted under <br />this greement, 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 <br />I 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 />AARP Date: <br />Eula T. Mills , District Coordinator <br />5 <br />