HomeMy WebLinkAboutCertificate of Insurance - BLDX-23-15597 23391s-\The Commonwealth of Massachusetts
Department of Industial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
\\:orkers' compensstion tnsurance Affidavit: Builders/contractors/Electriciars/plumbers.
TO BE FILED WITH THE PERr\IITTING .4.LITHORIT\'.ntl fo tion
Name (BusiDesyorganizationilndividual)i Lgat, 5
Address: J 4
Please Print Le bl
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City/State/Zipi ot('>G?L Phone#:'rtt, qLLtiQ,z
.Any applicanr thar check box #l must also fill out thc section bclow showing thcir workers' coopensation policy information"r Hofico*.ncrs n/ho submit thls affidavit indicadng thry arc doing a.ll work and then hirE ouEidc cont-actoE musr submit a new affidavit indicatrng such.rconfaclors that chcck this box must attachcd an additional shcct showing L\c namc of thc sub-.confdctoas and stalc whcthcr or not thosc entines havecmploye.s. lf rha sub-coofactors have employecs, thcy must providc their workcrs'comp. pohcy nurnber
I ! I am a employer with employees (tull and.ior pan-timc)..
2.fi1- a solc proprietor or parmership and have no chployces working for me in
any capacity. [No wo.licrs' comp. insunnce required.]
I arn a homeowner doing all sork myself [No worken, comp. insurance cquircd.j r
I am a ho(Ilcowner and \\,iil bc hiring contractoE to conduG all work on my p.operty. I will
cnsurc that dl cootractoE eithcr havc worl(gls' compcnsation irsurance or are solcproprictoE with Do qDployccs.
I am a grtrcral contractor and I havc hircd the sub-conEaclors lisrcd on the atachcd shccr
Ttesc sub-conEactpB havc crnployces and have workcrs' comp. irsumncc.l
Wc arc a corpoado! and its ofticcrs havc cxercised their right ofcrcmpdolr pcr MGL c.
152, g l(4), and we harc no employc.s. [No workers' comp. illsurancc rEquircd.]
Are you an employer? Check e approprirte bor Type of project (required)
New construction
Remodeling
Demolition
Building addition
Electical repairs or additioos
12. ! Plumbing repairs or additions
7.
8.
9.
l0
ll
I
l4 B
Roofrepairs
Other
I an an emploler that b providing workerc' compensation insurance for m1t employees. Below is the poticy andjob stteinformalion-
Insurance Company Name:
Policy # or Self-ins. Lic. #Expiration Date:
Job Site Address: City/State/Zip:Attach a copy of the workers' "omp"nsation poli-y decta. iiJ$lfiiiog in. poti"y nu*u"i*a uxpi.rtioo art.;.
Failure to secure coverage as required under MGL c. 152, $25A is a criminal violation punishable by a fine up to $1,500.00
and./or one-year imPrisonment, as well as civil penalties in the form of a STOP WORKbRDER and a fine olup to $250.00 aday against the violator. A copy of this statement may be forwarded to the Office of lnvestigations ofthe DIA for insurance
coverage verification.
I do hereby certify under pains and
Si AIUIC
of perjury thd.t the information provided above is true and correcl
Date:o -23t-
P e#:oa LL\L
OfJicial use only. Do notwrite in this area, to be completed by cit! or rown ofJicial
lssuing Authority (circte one):
1 Board of Heatth 2. Building Department 3. City/Town Clerk6. Other 4. Electrical lnspector 5. plumbing Inspector
Phone #:
City or Town:
Contact Person: