HomeMy WebLinkAboutCertificate of Insurance - BLDX-23-15562 22495\\iorkers' compensation ,.r'.r"""T#ffi,;{lr(!iJ"r,r,^"r",s/Electricians/plumbers.
TO BE FILED WITH THE PER]IIITTING .{TTTHORITY.
nt Info n e eP
N
,/o
ame (Business/Qrganization/lDdividual):
ddress:
CitylState/Zip o.J Phone #: ' 4 li - 1118 -bg4 t/
Type of project (required)
7. f New constn:ction
8. I Remodeling
t4.Yoth i:r{ (
Demolition
Building addition
Elecu'ical repairs or additioos
Plumbing repairs or additions
! Roofrepairs
9.
l0
1I
17
13
appl icant thar chcck box #l must also fill out thc secrion bclovi showing thcir workers'compensation policy informatio[
Homeowncn who subroit thls affidavlt indicating they are doing all work a$d thcn hirc ou6ide conE_actors must submit a new affidavrr indtcallng such.'LOntractors that chcck this box must atEchcd ar additional shcct showing lhc namc of the sub-contracto.s and statc whethcr or nor thosc entitics have
Ar. you etr .mploycr? Ch.ck th. appropriat. bor:
l.! I am a employer witit _employco (full and/or pan-timc).*
?.f, I am a sole poprictoror panncrship and havc no cmployccs working for me in
any capacity. [No wo*en' comp. insuraDcc rqquircd.]
3.! I am a homcowncr doing all work myseLf fNo workers,comp. insurance required_] i
4. z]1 am a homcowncr and will bc hiring con!-acto6 to corduct all wo* on my p.openy
cnsrnc that ali conE:actors eithcr havc worlicrs' compcnsation insurance or arc solc
Eopricto.s wirh no .nlployccs.
I aln a geocral contaactor and t havc hired thi sub-coflEactors listcd on the attrched shcet.
Thesc sub-contlactols havc cmployces and have work*s, comp. insruatce.t
We arc a corporation and its omccrs hava cxerciscd their right ofcxcmption pe. MGL c.
152, Sl(4), and w. have no employees. [No workers' comp. insurance rEquired.]
lwill
)
6
cmployecs. If thc suUcorfractoB havc loyees, thcy must providc their workcrs'comp. poliry nuurber
I atn an employer that is Providing workers' compensation insurancefor my enployees- Below is the poltcy and job siteinJornation
Insuraace Company Name:
Policy # or Seif-ins. Lic. #:Expiration Date:
Job Site Ad&ess: City/State/ZiD:Attach a coPy of the workers' compensation poti.y a-Jr."ti* p"gu 1ruolningile poti"y nurU.. *a.*p.rti", artq.
Failure to secure. cover€e as required under MGL c. I52, $25A is a criminal violation punishable by a fine up to $1,500.00and'/or one-year imprisonment, as well as civil penaities in the form of a STOp WORKbnOf,R uni" tin. of up to $250.00 aday against the violalor. A copy ofthis statement may be forwarded to the office of lnvestigations of the DIA for insurancecoverage verification.
,lzao
hereU certify -under the penalties of perjury that the ffi rmation provided aboye is true and correcl
O
pains and
P
atuie:
e#:
. Do not write in this a.rea, to be compteted by city or town ofJicial
lssuing Authority (circle one):
1 Board of Health 2. Building Department 3. City/Town Clerk6. Other 4. Electrical lnspector 5. plumbing lnspector
Phooe #:
OfJicial use only
City or Town:
Contact Person:
The Commonwealth of Massachusetts
D ep artme nt of I nd ustr ial A cc identsI Congress Street, Suite 100
Boston, MA 02114-2017