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Check the appropriate boz: Business Type(required): i 1.❑ I am a employer with employees(full and/ 5• ❑ Retail ` or part-time).* 6. ❑RestaurantlBar/Eating Esta.blishment F — - --_ _ --- 2. I am a sole proprietor or partnership and have no �, � Office and/or Sa1es(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] g• ❑Non-profit 3.❑ We are a corporation and its ofFicers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.�Manufacturing no employees. [No workers' comp. insurance required]* 11.�Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees Below is the poliey information. Insurance Company Name: Insurer's Address: City/Staxe/Zip: Policy#or Self-ins. Lic.# Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). Failure to secure coverage as required under Secrion 25A of MGL c. 152 can lead to the imposition of criminal penalties of a __- —- -- ------- ---- ----, fine up to$1,500.00 and/o e-year impnsonment,as w�civiT—peri�es-m����f��5P-�8�4�-�a f� of up to$250.00 a day ag i the v lato e advised that a copy of this statement may be forwazded to the Office of Investigations of the fo �c overage verification. I do hereby fy, n p ' s and penalties ofperjury that the information provided above ' true and correct. � Si ature: Date: /S�- Phone#: f � � Official use only. Do not write in this area,to be completed by city or town officiaL City or Town• Permit/License# ' Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office � 6.Other � � Contact Person• Phone#• www.mass.gov/dia Technology lnsurance Campany Q Stock Insurance Company WORKERS COMPENSATION WC 99 OQ 01 B AND EMPLUYERS LIABILITY (NSURANCE PO�ICY INFORMATION PAGE Ncci Code:39071 ' 1. Insured: Policy Number: TWC3461568 Gaytri Krupa Corp. ; DBA:Ambassador Inn 8c Suites i 1314 Route 28 Individual Partnershig � South Yarmauth,MA 02664 X Corparation i' Other workplaces not shown ubave: Federal Tax ID: See Estension of Information Page Praducer: Risk Id: AmTrust North America,Inc. RenewaL af: TWC3400962 __ _ c/a GH Dunn Insurance Agency,lnc. __ P.O.Box 497 ___ ; Mattapc�i�ett,MA 02739 � 2. The policy�eriod is from 3/912015 to 3/9/2016 12:01 u.m.ut the insured's mailing address. � 3. A. Workers Compensation Insurance:Part One af the policy appiies to the Workers Compensation Law of the states listed here:Massachusetts B. Employers Liabi(iCy Insurance:Part Two of Che policy applies to Kork in eack�state listed in item 3.A. The limits af our liability under Part Two are: ' State BadiIy Injary by Accident Bodily tnjury by Disease Bodily 7njury by Disease ' $500,000 each accident �SQp,040 palicy Iimit �SOQ,t}00 each employee 4 C. Other States Insurance:Part Three of the policy applies to the states,if any,listed here: � Atl states except ND,OH,WA,WY and State{s)Designated in It�m 3A. D. This policy includes chese endorsements and schedules:See Extensian of Information Fa�ge k 4. The premium for this policy will be determined by our Manuais of Rules,Classifications,Rates and Rating � Plans.Atl'mformation required below is subject to verification and change by audit. , Se�Extension of Information Fage TOTAL ESTIMATED APVNUAL PREMIUM 1,154 STATE ASSESSMENT 50 TOTAL ESTIMATED COST � 1.,2tW Minimum Premium � 4Q6 Deposit Premium � , 1,2Q4 Issue Date: 1/2&/2015 Countersigned by: Authorized Representative _ �:�' __ i M � � � � � � N , � : � . . . . .._-_..._. . � . . .._ ....... ...__..