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� + � The Commonwealth of Massachusetts
Department of Industrial Accidents
• - Office of Investigations
� 1 Congress Street, Suite 100
Boston,N�4 021�4-2017
� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv
Business/OrganizationName: Blue Rock �lub Inc.
Address: 39 Todd Road
City/State/Zip: So .Yarmouth, MA 02664 Phone#: 508-398-6962
Are you an employer? Check the appropriate boz: Business Type(required):
l.� I am a employer with employees(full andl 5• ❑ Retail
or part-time).* 6. ❑ Restaurant/BarlEating Establishment
2.❑ I am a sole proprietor or partnership and have no �. � Office and/or Sales(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 aze a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 12.❑X Other S e a s o n a 1 R e s o r t
*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 corporadon 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 policy information.
InsuranceCompanyName: Zurich American Ins o
Insurer's Address: s e e a t t a ch e d
i
City/State/Zip: �
!
Policy#or Self-ins.Lic. # W['R 1 A ti��5 Expira.tion Date: �-1 -1 4 '
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). �
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a `
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of i
Investigations of the DIA for insurance coverage verification.
I do hereby tify,under the ains and penalties of perjury that the information provided above is true and correc�t.
Si ature. �/�2-' Date: 11-1-13
Phone#: 508-398-2293
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town• ��}�2M0�]T1� Permit/License# '
I�ring� a� 'rcle one): '
1.Board of Health 2. uilding Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office ;
�
Contact Person• Phone#• �8-3�"�-�"��. x !Z��
� www.mass.gov/dia
� � �
��'� OP ID:KD
ACOROo- DATE(MMIDD/YYYY)
: �� CERTIFICATE OF LIABILITY INSURANCE o2/28/13
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
, BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(Sj, AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER � CONTACT �
Phone:610-279-8550 NAME:
The Addis Group,Inc. Fax:610-279-8543 PHONE FAX
2500 Renaissance Blvd.Ste 100 a�c No �ce: arc No:
King of Prussia,PA 19406-2772 aDDR�ESS:
Jeffrey A.Grebe rRoouceR .DAVEN-1
CU5T0
� INSURER S AFFORDING COVERACaE � � NAIC#
INSURED Davenport Realtyl INSURERA:AIII@fIC811 ZUfICII IIlSUr8t1CB CO. 40142
Blue Rock Motor Inn wsuReRa:Zurich American Insurance Co. 16535
c/o Davenport Realty Trust
Stephen Aschettino iNsuReR c:
20 North Main St. INSURERD:
South Yarmouth„MA OLB64 INSURERE:
� INSURER F:. �
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
- CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR 7ypE OF INSURANCE ADDL UB ppuCY NUMBER � MMlDD� MM DDY� LIMRS
LTR
GENERAL�LIABILITY � � � �fACH OCCURRENCE $ � ��OOO�OOO
B X COMMERCIAL GENERAL LIABILITY GL08196255 03/01/13 03/01l14 pREMiSES Ea occurrence S 500,000
CLAIMS-MADE �OCCUR MED EXP(Any one person) $ �,���
PERSONAL&RDV INJURY $ 'I,OOO,OOO
� GENERALAGGREGATE S Z,OOO,OOO
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,000
� X POLICY PR� LOC � � � $
i AUTOMOBILE LIABILITY . . COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident) �
B aNv nuTo BAP8196256 03/01/13 03/01/14 BODIL.Y INJURY(Per person] $
X ALL OWNED AUTOS BODILY INJURY(Per accident) 8
SCHEDULED AUTOS PROPERTY DAMAGE
X HIRED AUTOS (Per accident) $
X NON-OWNEDAUTOS $
X 250 Comp s
UMBRELLA IJAB OCCUR � EACH OCCURRENCE $
EXCES5 LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
� RETENTION S a
I
i WORKERS COMPENSATION X WC STATU- OTH-
� AND EMPLOYERS'LIABILITY Y/N �
A ANYPROPRIETOR/PARTNER/EXECUTIVE WC8196035 03l01/13� 03/01/14 E.L.EACHACCIDENT $ ������0��
� OFFICER/MEMBER EXCLUDED? ❑ N�A
� (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 1,000,�00
If yes,describe under
i DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 'I,OOO,OOO
�
i DESCRIPTION OF OPERATIONS/LOCATiONS I VEHICLES (Attach ACORD 101,Addidonal Remarks Schedule,if more space is required) _ � � �
i
CERTIFICATE HOLDER CANCELLATION
YARMO-0
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Route 28
South Yarmouth�MA OZSB4 AUTHOR�ZEDREPRESENTATIVE
I T�� � ��
� O 1988-2009 ACORD CORPORATION. All rights reserved.
i
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
;
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