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Home My WebLink AboutCertificate of Liability Insurance • • The Commonwealth of Massachusetts e.5/ Department of Industrial Accidents =apt_ 1 Congress Street,Suite 100 --.1111.114_= 4 Boston,MA 02114-2017 www.massgov/dia IMP Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual):industrial Communications,LLC Address:40 Lone Street City/State/Zip:Marshfield,MA 02050 Phone#: 781-319-1111 Are you an employer?Check the appropriate box: Type of project(required): 1.1:1i am a employer with 50 employees(full and/or part-time).* 7. Q New construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required] 3.0 1 am a homeowner doing all work myself.[No workers'comp.insurance required]t 9. Demolition 10❑Building addition 4.0 lama homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 l am a general contractor and I have hired the subcontractors listed on the attached sheet. 13.0Roof repairs These sub-contractors have employees and have workers'comp.insurance; 14.DOther telecommunications 6.❑We arc a corporation and its officers have exercised their right of exemption per MGL c. 152,11(4),and we have no employees.[No workers'comp.insurance required] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information - Insurance Company Name: United States Fire Insurance Company Policy#or Self-ins.tic.#:4087330398` p Expiration Date:°"1/19Job Site Address:C , (.Oh`kz PQM City/State/Zip: YQ)r rf(9Vih I tern o966,t Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. - I do hereby certify r the •' • d penalties of perjury that the information provided above is true and correct IF Signature: I// // j nein10 Date: Fii3h6 phone#: 7 ` I -31q - 1056 Official use only. Do not write in this area,to be completed by city or town official City or Town: PermiULicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing inspector 6.Other Contact Person: Phone#: a'eV CERTIFICATE OF LIABILITY INSURANCE DATE(MMIOD YYYY) 8/13/2018 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(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or 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 Ken Christianson CONE The Driscoll Agency .(A/C Fwr 781-681-6656 Not 781-681-6686 93 NorwellLongwater Circle (A/C N MA 02061 E-MAIL R.kchristianson@driscollagency.com MSURER(SLAFFORDINO COVERAGE NAIL a INSURER A:United States Fire Insurance Co 21113 INSURED 2066 INSURER e:The North River Insurance Company 21105 Industrial Communications&Electronics,Inc. INSURER C;Travelers Property Casualty Company of 25674 Industrial Tower&Wireless,LLC Industrial Communications,LLC INSURER 0; 40 Lone Street INSURER E: Marshfield MA 02050-2102 _INSURER F: COVERAGES CERTIFICATE NUMBER:412204288 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. , XP LTR TYPE OF INSURANCE ADOL WVD POLICY NUMBER (MMJJDOA'YYYL(MM ODNY EFF POLICY YYY1 LIMITS A X COMMERCIAL°recanLwary 5432200173 1/1/2018 1(1/2019 EACNOCCURRENCE $1,000000 AMAGE TO RENTED CLAIMS.MAOE n OCCUR PREMISES IEa occurrence) $300,000 X XCU Included MED EXP(My one pawn) $15,000 X Contractual Llab PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE OMIT APPLIES PER GENERAL AGGREGATE $2,000,000 POLICY X as- n t.0PRODUCTS•COMPIOP AGO_52,000,000 OTHER $ A AUTOMOBILE LIABILITY 1337429349 1/1/2018 1/1/2019 commis,SINGLE].EDMR 51000000 ANY AUTO BODILY INJURY(Per person) $ , — Au ETOS DONLY x SCHEDULED BODILY INJURY(Per aoodent) $ X AUTOS ONLY x AUItOSONLY PROPERTY DAMAGE $ (Pazaccmen0 . $ - B X UMBRELLA LIAR X OCCUR 5811099309 1/1/2018 1/1/2019 EACH OCCURRENCE $10,000.000 — EXCESS LMB CLAIMS-MADE AGGREGATE $20.000.000 DFD RETENTIONS $ A WORKERS COMPENSATION 4087330398 1/1/2018 1/1/2019 ANO EMPLOYERS'LMBILITY YIN x STATUTE ERS ANY PROPRIETORPARTNERIEXECUTNE E.L EACH ACCIDENT 31,000,000 OFFICERMEMBER EXCLUDED? I N NIA (Mandatary N NH) E.L DISEASE•EA EMPLOYEE $1,000,000 Nyn dosvlbe under DESCRIPTION OF OPERATIONS below E.L DISEASE•POLICY LIMIT 51,000,000 C Instillation Floater QT660221D1260TIL18 1/12018 1(12019 Job Site $300,000 In Transit $100.000 Temp Location $200,000 DESCRIPTION OF OPERATIONS!LOCATIONS(VEHICLES(ACORD lel,AddMonal Remarks Schedule,may be attached If mare apace Is required) Industrial Communications Is included as Additional Insured for Automobile Liability on a Primary Basis for the conduct of the(Named) Insured,but only to the extent of that liability. Notice of cancellation provision is 30 days,except 10 days applies for non-payment of premium. Industrial Communications Is included as Additional Insureds for General Liability and Excess(Umbrella)Liability as required by a signed See Attached... CERTIFICATE HOLDER CANCELLATION 30 , SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Industrial Communications THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 40 Lone Street ACCORDANCE WITH THE POLICY PROVISIONS. Marshfield MA 02050 AUTHORIZED REPRESENTATIVE /ggf 17 I ®1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ' • F r AGENCY CUSTOMER ID:2066 LOC R: AC ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED The Driscoll Agency , Industrial Communications&Electronics,Inc. . Industrial Tower&Wireless,LLC POLICY NUMBER Industrial Communications,LLC 40 Lone Street CARRIER NAIL CODE Marshfield MA 02050-2102 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TO-LE: CERTIFICATE OF LIABILITY INSURANCE written contract or agreement with the Named Insured. The Additional Insured coverage for General Liability&Excess(Umbrella)Liability detailed above applies on a primary,non-contributory basis where required by a signed written contract or agreement with the Named Insured. The General Liability,Excess(Umbrella)Liability,Automobile Liability,and Workers Compensation/Employers Liability Policies include a Waiver of Subrogation in favor of - Industrial Communications on whose behalf the Named Insured Is required to obtain this Waiver under a written contract or agreement executed prior to a loss. • • • • • ACORD 101 (2008101) C 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD r