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C17 -- 65. `0. o . 1-157S772
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The Commonwealth of Massachusetts
i=r� � t Department of Industriat4ccidents
1 Congress Street,Suite 100 .r..
Boston,RPA 02114-2017 •
%;, www.mass.gov/dia •
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Workers'Compensation Insurance Affidavit:General Businesses.
TO BE PILED WITH THE PERMITTING AUTHORITY •
R
Applicant linformation Please Print Legibly v l
,
Business/Organization Name:E.F.WINSLOW PLUMBING&HEATING CO.,INC
Address:e REARDON CIRCLE \d
City/State/Zip:SOUTH YARMOUTH,MA 02664. Phone#:508-3947778
Are you an employer?Check the appropriate box: Business Type(required): \ (�
1.0 I am a employer with 10 employees(full and/ 5. 0 Retail .\ 1 \
2.0 orpart-time).* 6. ❑Restaurant/Bar/EatingEstablishment V /�
I am a sole proprietor or partnership and have no
employees working for me in any capacity. 7. 0Office and/or Sales(incl.real estate,auto,etc.)
• [No workers'comp.insurance required] 8. 0 Non-profit.
3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment •
their right of exemption per c.152,§1(4),and wehave 10.0 Manufacturing •
no employees.[No workers'comp.insurance required?*
4.❑ We are a non-profit organization,staffed by volunteers, 11.❑Health Cera
with no employees.[No workers'comp.Insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the sectioa6ylA.W shovringiheirworkers'.compensation policy information.
salftlia fofpmaCa officers>]aveeeTemptedrlremselves,but the corporation has ether employees,a workers'compensation policy is required and such an
organization should checkbox tit.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance CompanyName:ARROW MUTUAL INSURANCE COMPANY
Insurer's Address:23 COMMONWEALTH AVE
City/State/Zip: CHESTNUT HILL,MA 02467
Policy#or Self-ins.Lin#1821 A Expirationate:01/01/201
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 that a copy of this statement may be forwarded to the Office of
•Ths
Investigations of the DIA for insurance coverage verification.
Ido hereby cent . the,a' 5 and.enaltieso perjury that the information provided above is true and correct
Si: afore:.__ �'!t/"`" / ,a.en
Date: \.\'`•
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Phony#;506-394-7778
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Official use only. Do not write in this area,to be completed by city or town official Q
City or Town: Permit/License#
Issuing Authority(circle one):
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1.Board of Health 2.Building Department 3.City/Towa Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
t
wvm.mass.gov/dia
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