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Home My WebLink AboutWC Affidavit .4c '11 .REP 7A c e s c 9 z CERTIFICATE OF LIABILITY INSURANCE I DATE(MMIDD/YYYY) 02/01/20 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(ies)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 "AM Roger and Gray Processing PHONE BALDWIN KRYSTYN SHERMAN PARTNERS LLC FAX WG No.ExU (508)398-7980 (A/C _ _No): 4211 West Boy Scout Blvd Suite 800 DAD a's& mail@rogersgray.com -COVE Tampa INSURER(S)AFFORDING COVERAGE NAIC N FL 33607 INSURER A: AMGUARD INSURANCE CO INSURED42390 CAPIZZI HOME IMPROVEMENT INC INSURERS: -- --INSURER C 1645 NEWTOWN ROAD NSURER RERS: COTUIT MA 02635 -- — COVERAGES INSURER F CERTIFICATE NUMBERS 858208 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. INSR i —_._ rADl3CSU8R LTR TYPE OF INSURANCE POLICY EFF J POLICY EXP INSO WW1 POLICY NUMBER COMMERCIAL GENERAL LIABILITY IMMIDprYYYYI I iMMIDD/YYYY�! LIMITS EACH OCCURRENCE j $ 7_ j CLAIMS MADE I 1 OCCUR DAMAGE YO`RENTECS— PREMISES(Ea occurrence, !$ — — MED EXP(Any one person) $ N/A GEM_AGGREGATE LIMIT APPLIES PER PERSONAL&ADV INJURY $ _E POLICY jECOT I I LOC GENERAL AGGREGATE 1$ OTHER: PRODUCTS-COMP/OP AGO •`$$ AUTOMOBILE LIABILITY S ANY AUTO (Ea aacddentINGLE LIMIT $ ---- OWNED ;SCHEDULED BODILY INJURY(Per person) $ I— I AUTOSIRED ONLY 1 AUTOS N/A AUTOS ONLY NON OWNED ` BODILY INJURY(Per accident) $ — AUTOS ONLY 2 1 (Per accident) $ _ CLAIMS-MADE UMBRELLALIAB 1. p— r OCCUR EXCESS LABN/A EACH OCCURRENCE $DED RETENTION$ AGGREGATE $ WORKERS COMPENSATION 1 AND EMPLOYERS'LIABILITY I v S ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N X j STATUTE I ERH A OFFICER/MEMBEREXCLUDED? N/A I N/A I N/A — (Mandatory In NH) i R2WC377754 12/25/2022 12/25/2023 EL EACH ACCIDENT $ 1,000,000 H yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-EA EMPLOYEE$ 1,000,000 E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A 1 j IESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govAwd/workers-compensationrnvestigations/. :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN __ ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE MA 02601 Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA CORD 25 2016/03 ©1988-2015 ACORD CORPORATION. All rights reserved. ( ) The ACORD name and logo are registered marks of ACORD ~ 1 ne t,ummonweuun of tnassucnusetis mot Department of Industrial Accidents � _ 46, Office of Investigations 94 I= 600 Washington Street aAr tzt Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): CAPIZZI HOME IMPROVEMENT INC Address: 1645 NEWTOWN ROAD City/State/Zip: COTUIT, MA 02635 Phone #: 508-428-9518 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 40+ 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 New construction listed on the attached sheet. 7. Remodeling 2. I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance. 9 1/ Building addition required.] 5. We are a corporation and its 10. Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions 3. I ant a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13. Other 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. tContractors 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: AMGUARD INSURANCE COMPANY Policy#or Self-ins.Lic.#: R2WC377754 12/23/2023 Expiration Date: Job Site Address: 72 CAPTAIN CHASE ROAD City/State/Zip: SOUTH YARMOUTH, N 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 certifyunder the pains and penalties of perjury that the information provided above is true and correct Signature: Date:04/21/2023 Phone#: 08-428-9518 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.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: