HomeMy WebLinkAboutCertificate of Insurance - BLDX-23-15593 23308The Commonwealth of Massachusetts
D ep artment of I n d ustrial A cc ide nts
I Congress Street, Suite 100
Boston, MA 02114-2017
\\:orkers, compensation ,r,,.r.""'I/;frfft;{?rY!!Ja,,r,,"r"*Erectricians/prumbers
TO BE FILED WITH THE PERT}IIT'TING .{tITHORITY.
cant In atio
Name (BusinesVO.garization {ndividual) :
Address:
PI rint L
l
Ar. you an .mploycr? Ch.ck the approprirte bor:
L! I am a employer with ernployees (full and/or pan-time).*
Z.RI am a sote pronrietor or partnership and have no employees workrng for me rnany capaciry. [No worliers'comp. insunncc requrrcd.]
I am a homeowner doing all work myself. fNo workcrs'comp idsurance requhed ] i
I am a homeownc, and will be hiring contuactors to conduct all wo(k on my propefly. I willen$re that all conE-actors eithca havc workcrs' cornp.nsation iror.",r"" or'aic .it. '
proprietors with no ehployees.
I am a gencral conts-actor and I have hired the slb-contractoas listed on the attached sheet_These sub-contactoE have employecs and hav" *ork"rs, comp. insura,"c.t
Wc ar€ a corpoEtion and its omcers have exercised their aigh! of exempoon per MGL c.152, Sl(4), and we have no employees. [No workcrs, comp] insuraoce rcquircd-]
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City/Stzte/Zip Phone #:
applicant thar check box #l iiust also fill out thc section below showing their workers'compensation poliry information.i11omeo\r,,Ders who submit this afEdavit indicating they are doing all work and then hirc ouEide conE-aclors must submit a new affidavit indrcating such_lcontractors that check *!is box rxust attached an additional sheet showing the nalne ofthe sub-coolractors and state whether or nor those entities haveehployees. If the suLcont-actors have enrployees,they must providc their workcrs,
7.
8.
9.
10
Type of project (required)
New construction
Remodeling
Demolition
Building addition
1 l.X Electrical repairs or additions
12. f, Plumbing repairs or additions
i.3. ! Roof repairs
,OF Other
I am an employer th
injor,"rlq.tio n-
Insuralce Company Name
comp. poliry number
al is providing workers' compensation insurance for my emproyees. Bero, b the poricJ andjob site
Expiration Date:
Job Site Address:=-..-...-
Attach a copy orih "rl'lili;"_*;
"_,-r... *,.,
Failure to secure covemge as required under MGL c. 152, $25A is a criminal violation punishable by a fine up to s1,500.00and'/or one-year imPrisonment, as well as civil penalties in the fonn of a STop woRK oRDER ania fine of up ro $250.00 aday against the violator. A copy of this statement m"y u. ro*"ra"i to the of6ce of Investigations ofthe DIA for insurancecoverage verification.
I do hereby certify under the ains andpenalties of perjury that ttlep information provided above k tr
Date
ud and cortect
zo z7
P one 71, b 'ftf t
0 not tetite in this drea, to be completed by citf or town ofJicial
lssuing Authority (circle one):l. Board of Health 2. Building Department 3. Ciry/Town Clerk6. Other 4. Electrical Inspector 5. plumbing Inspector
Phone #:
OfJicial use only. D
City or Town:
Contact Person:
West Yarmouth, MA 02679
Policy # or Self-ins. Lic. #: