HomeMy WebLinkAboutWorkers Compensation DeclarationPage 1
CITY OF PALM DESERT
73510 Fred Waring Drive
Palm Desert, CA 92260
Tel. 760.776.6477
Email: filmpermit@palmdesert.gov
California Worker’s Compensation Declaration
Legal Name or DBA Name:
You are required to complete this form because you have not filed a certificate regarding
workers' compensation insurance with the City of Palm Desert. California law requires all
employers to carry workers' compensation insurance, even if they have only one employee.
If you are the sole owner and you have no employees, you may not be required to carry
workers' compensation insurance. It is your responsibility to comply with the law. If you do
not know whether you are required to carry workers' compensation insurance, find out by
contacting the California Department of Industrial Relations ("DIR"). Information is also
available on the DIR's website at http://www.dir.ca.gov. You should also consult with your
attorney, insurance agent or broker, or carrier regarding the specifics of your situation and
your options. If you are subject to the Workers’ Compensation Laws of California, you must
promptly file a certificate of Workers’ Compensation Insurance with the City of Palm Desert.
If you have a certificate of self-insurance from the DIR, you must file that certificate with
the City of Palm Desert. When completing this form, remember that the term “employee”
includes clerical persons as well as any other persons employed by your company including
drivers.
ACKNOWLEDGEMENT
(Initial) California Labor Code § 3700 requires employers to carry workers'
compensation insurance or to obtain a certificate from the Director of Industrial Relations
demonstrating that the employer is self-insured. California Labor Code § 3700.5 makes it a
criminal offense for an employer to fail to secure compensation as required by the workers'
compensation provisions of the Labor Code. Violation of Labor Code § 3700 is punishable
by a fine of up to $10,000 and/or imprisonment for up to one year.
(Initial) California Labor Code § 3710.1 provides that where an employer fails to
provide compensation required under § 3700, the Director of the Department of Industrial
Relations shall issue a stop order, prohibiting the employer from using employee labor until
such time as the employer complies with the provisions of § 3700. Labor Code § 3710.2
makes it a criminal offense to disregard such stop orders.
(Initial) I acknowledge that if evidence is found that contradicts this declaration,
the City of Palm Desert will promptly notify all relevant state agencies to ensure full
insurance compliance required by Workers’ Compensation Laws of California.
Page 2
California Worker’s Compensation Declaration
(Initial) I understand that California Labor Code § 3700 et seq. requires employers
to provide workers’ compensation insurance coverage for any employees of my business.
I hereby warrant that this business is exempt from the California Labor Code provisions
regarding workers’ compensation insurance because it has no employees.
(Initial) I agree to hold the City of Palm Desert and its officers, officials, employees,
and agents harmless for loss or liability which may arise from the failure of the above-
mentioned business to comply with the laws of the State of California regarding workers'
compensation insurance.
(Initial) If I hire employees in the future, I will immediately notify the City of Palm
Desert’s Risk Manager and provide a certified Workers’ Compensation certificate to the
City.
CERTIFICATION
I (we) certify (or declare) under penalty of perjury, under the laws of the State of California,
that I (we) have read and understood the above stated requirements regarding Workers’
Compensation and that I (we) am (are) in compliance. I (we) certify (or declare) that the
forgoing is true and correct.
Executed this day of 202 at , California.
Signature of Applicant
Print Name of Applicant
Signature Owner, Officer, Director or Partnership