HomeMy WebLinkAboutBLDE-21-000947 (2) AThe Commonwealth of Massachusetts
_�, Department of Industrial Accidents
^ h Office of Investigations
Lafayette City Center
2Avenue de Lafayette,Boston,MA 02111-1750
Workers' Compensation Insurance Affidavit: General Businesse
A licant Information s
Please Print Le ibl
Business/Organization Name: E.F. WINSLOW PLUMBING & HEATING CO, INC.
Address:8 REARDON CIRCLE
City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778
Are you an employer? Check the appropriate box:__
Business T
1. ■ I am a employer with 90 YPe(required): - —_-_-
employees (full and/ 5. Retail
or part-time).*
❑ -- -
2.ElI am a sole proprietor or partnership and have no 6. El Restaurant/Bar/Eating Establishment
7. 0 Office and/or Sales(incl.real estate, auto, etc.)
employees working for me in any capacity.
3.E [No workers' comp. insurance required] 8. Ej Non-profit
We are a corporation and its officers have exercised
their right of exemption per c. 152, 1 4 9. El Entertainment
§ ( ),and we have 10.0 Manufacturing
4.Eno employees. [No workers' comp, insurance required]**
l We are a non-profit organization, staffed by volunteers, 11 Health Care
with no employees. [No workers' comp. insurance req.] 12.0 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 of
organization should check box#1. P policy is required and such an
Iam an employer that is providing workers'compensation insurance for my employees Below is the policyinformation.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY f tzon.
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic. #1909A
orr o Expiration D ate:01/01/2021—__
Attach a copy of the workers' eompensati
policy deciaration page(showing the policy number and expiration date).
Failure to secure coverage as required under§25A of MGL c. 152 can lead to the imposition of criminal penalties
to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP
$250.00 a day against the violator. Be advised that a copyp tes of a fine up
the DIA for insurance coverage verification. of this statement may be forwarded to the Off ORDER
of Investigations e of up to
g ns of
I do hereby cer ' e the ins and o penalties perjury that the information provided p fp J
P d above is true and correct.
Si ature:
Phone#; 508-394-7778
Date: 01/02/2020
Official use only. Do not write in this area,to be completed by city or town official.
City or Town:
Issuing Authority(check one): Permit/License#
1•0Board of Health 2.0 Building Department 3.
❑
50 Selectmen's Office 6.QOther City/Town Clerk 4.[]Licensing Board
Contact Person:
Phone#: