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The Commonwealth of Massachusetts
Department of Industrial Accidents
d I Congress Street, Suite 100
F Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name: Waterwheel 28 Inc
Address:1323 Route 28
City/State/Zip: South Yarmouth MA 02664
Are you an employer? Check the appropriate box:
1.21 I am a employer with 4 employees (full and/
or part-time).*
2. ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3. ❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
no employees. [No workers' comp. insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
Phone #:508 398 2125
Business Type (required):
5. Q Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10. ❑ Manufacturing
I L ❑ Health Care
12. ❑ 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 #l.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: MA Retail Merchants WC Group Inc.
Insurer's Address: PO Box 859222-9222
City/State/Zip: Braintree MA 02185
Policy # or Self -ins. Lic. # 014005030531118 Expiration Date: 01 /01 /2019
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 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
Investigations of the DIA for insurance coverage verification.
I do hereby c/eerrtify, under the poi Jn's and pppenalties/of perjury that the information provided above is true and correct.
Si¢nattire: /C.I%'%%%/ C r� J(�(z l ✓.Q3/UC(%� Date: /117111
Phone #• 5 A" 3�d 21�-5
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
INFORMATION PAGE
RENEWAL AGREEMENT
Insurer:
MA Retail Merchants WC Group Inc.
PO Box 859222-9222
Braintree, MA 02185
(Carrier Code: 34355)
1. The Insured: Waterwheel 28, Inc.
Waterwheel Liquors
Mailing Address: 1323 Route 28
South Yarmouth, MA 02664
Other workplaces not shown above:
NO OTHER WORKPLACES FOR THIS POLICY
PRODUCER: Agent# 641
Wm F Borhek Insurance Agency, Inc.
311 Plymouth Street
Halifax, MA 02338
Carrier Policy #: 014005030531118
Carrier Prior Policy #: 014005030531117
Fein:
Type of Business: Corporation
Risk ID:
2. The policy period is from 12:01 a.m. on 1/01/2018 to 12:01 a.m. on 1/01/2019
at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers
Compensation Law of the states listed here:
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each
state listed in Item 3.A. The limits of our liability under Part Two are:
Bodily
Injury
by
Accident
$
100.000
each accident
Bodily
Injury
by
Disease
$
500,000
policy limit
Bodily
Injury
by
Disease
$
100,000
each employee
C. Other States Insurance:
D. This policy includes these endorsements and schedules:
WC000000C(01/15) WC000414(07/90) WC000422B(01/15) WC200102(01/14) WC200301(04/84)
WC200302A(09/08) WC200303D(08/10) WC200306B(06/13) WC200405(06/01) WC200601A(07/08)
4. The premium for this policy will be determined by our Manuals of Rules,
Classifications, Rates and Rating Plans. All information required below is subject
to verification and change by audit.
Classifications Code Premium Basis
No. Total Estimated
Annual Remuneration
SEE SCHEDULE OF OPERATIONS
Total Estimated Annual Premium $ 1,214.00
Minimum Premium $ 216.00 Expense Constant $
Rate Per Estimated
$100 of Annual
Remuneration Premium
00 Deposit Premium $ .00