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The Commonwealth of Massachusetts 1
Department bf Industrial Accidents
r =;ai�I__ l Office of Investigations
4— .. 1 Congress Street, Suite 100
•4 ,11if= a Boston, MA 02114-2017
••-• www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
•
Name (Business/Organization/Individual): E. F. WINSLOW PLUMBING & HEATING CO.,INC.
Address:8 REARDON CRCLE
City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778
Are you an employer? Check the appropriate box: Type of project(required):
1.0 I am a employer with 70 4. 0 I am a general contractor and I
employees(full and/or part-time).* have hired the subcontractors 6. 0 New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box III 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:ARROW MUTUAL INSURANCE COMPANY
Policy#or Self-ins. Lic. #: 1794 A Expiration Date:01/01/2016
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MOL 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 t tat a copy of this statement may be forwarded to the Office of
Investigations oft DIA or' uranc; co erage veri c tion.
I do hereby certify an, e. ins and,enalties erjury that the information provided above is true and correct,
/fV 2016 c
Signature: K v Date:
phone#: 508-394-777. ..
Official use only. Do not write in this area,to be completed by city or town official.. - i
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
^ ''"Phone#:
Contact Person: