HomeMy WebLinkAboutworkers compThe Co mtnonwealth of Massacltusetts
D epartment of I ndustrial A cc ide nts
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
\\:orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH TIIE PET{\IITTING .4,ITTHOzuTY.
lica t ation e b
Name (Business/Orgarization{ndividual):
Address: LL //orsg
Ors fuc o lLc a*sa-nJ f'/ u,ra- rt
/
Pr*.1 rJ
Ar. you .tr .mplorcr? Ch.cL th. eppropri.t. bot:
1.ffi I am acmployerwi$ 3 c.ploy".s (tult and/or pan-timc).i
I arn a sole proprictor or parhcrship and have no emp loyees working for me in
any capacity. fNo workcn' comp. insuranc. rcquircd.]
I aJIl a homeowncr doing all work hysclf [No workers' comp. insu-ance requhed.] 'r
I am a horlcowncI aIId will bc hiring contr.actoG to conduct all work on my propcrty. I will
cnsure that a.ll conE-acloE cithcr havc workqs' compcnsation iruurancc or arc solc
pEprictors with no amployces.
I anl a gcocral contaactor and I havc hircd thc sub.coflEactors listcd on thc afiachcd shecl
Thasc subconEactpE have cmployrcs and bavc workc6' comp. irlsl,lrancc.t
We aI! a corporalioD and ils officcrs havc cxerciscd thcir righ! ofcxemptjoD pcr MGL c.
152, $l(4), and wc hav. no employccs. [No workeG' comp. ilsurancr rcquiEd.l
5
6
3.
4.
CitylStztelZip,t/.yr4 oa4L HA o)6X3 Phon"*, 5o&-3 CO- /3 8{
Type of project (required):
7. f] New constructior
8. I Remodeling
9. E Demolition
Building addition
Elecfical repairs or additions
12. f] Plumbing repairs or additions
13. f] Roofrep
10
II
r4.El oth"rS,tA-r) )*alrs
w9
'Any applicant that checks box #l must also fill out thc scction below showing their workers' compcnsalion policy information.
T Homcorrmcrs who submit this affidavit indicaning thry are doiag all work ana then hire ouBidc cont'actots must submir a ncw affidavir indicating such.tcontractors lhat chcck this box must attachcd an additional sheei showing lhe namc of th. sub-cootractors and state whetier or not thosc cntitics havc
eftployccs. lfth! sub-cooEactors havc employccs, thc/ must providc thcir workcrs'comp. policy number.
I a.m an emPlo)et that is providing worken' compensation insurancefor my enployees. Below is the poticy andjob site
inJornntion-
Insurance Company Name:Zu*o-& tQ-r /
Policy # or Self-ins. tic. *: WC y' 01 q x2 ,o{Exp l;aaonDag: y'L 2"4
uasitetaarcss:?Z fZ)ver SJr<lrf city/statdzi .l /arn
"11"
A 0L66qD
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expira OD te).
Failure to secure coverage as required under MGL c. 152, $25A is a criminal violation punishable by a hne up to $1,500.00
and./or one-year imPrisonmert, as well as cMl penalties in the form of a STOp WORKbnOeR uni
" fin. of up to $250.00 aday against the violator. A copy of this statement may be forwarded to the office of lnvestigations ofthe DIA for insurancecoverage verification.
I do hereby certify undet te
P e#3-
pains and penalties of perjury that the information provid.ed above is hud and correct.
o o XnzItco-
use only. Do not write in this area, to be conpteted b cit! or tolen ofrtcial
Issuing Authority (circle one):
l. Board of Health 2. Building Department 3. City/Town Clerk6. Other 4. Electrical Inspector 5. plumbing Inspector
Phooe #:
OfJicial
City or Town:
Contact Person:
-PermiUlicense#
C
ACORD-
COVERAGES CERTIFICATE t{U BER: 159385271 REVISION NUMBERi
OATE {TT'DD/YYYYI
't2t11t2023
THIS CERTIFICATE IS ISSUED AS A I'ATTER OF INFOR ATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE OOES NOT AFFIR]'ATIVELY OR NEGATIVELY A END, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETMEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, A'{D THE CERTIFICATE HOLDER,
IMPORTANT: It the certificate holder is an ADOrnONAL INSURED, tho policy(ies) must have ADDITIONAL INSURED provisions or bo endolsed.
lf SUBROGATION lS WAMD, subiect to tllg terms and conditlons ot the policy, certain policio! may rEquins an ondonBmonl A statqment on
this certjficate does not confer rights to the certificate holder in lieu of such endorsement(s).
PROOUCER
Eastem lnsurance Group LLC
233 West Central Sl
Natick MA 01760
It{suRrEo
ALT Construclion LLC
22 Horse Pond Road
W Yarmouth MA 02673
ALTCONS4l
ADOt SUARINSR
LTR
THIS IS TO CERNFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAT'ED ABOVE FOR THE
INDICATED, NOT\A/ITHSTANOII{G ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VUTH RESPECT TO ',l,{ICH THIS
CERIIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFOROEO BY THE POLICIES DESCRIBEO HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOV\,t'l MAY HAVE BEEN REDUCED BY PAID CLAIMS
IYPE OF INSURANCE NUlllBER LIMITS
POLICY PERIOD
11,000,000EACH OCCURR€NCE
D}'FGFIO'FENTE
PREMISES IE' tr',JlreE]r 100.000
MEO D(P (Aiy dl€ pe.56)a 5,000
PERSONAL A ADV INJURY ! 1.000.000
GENERAL AGGREGCTE
PRODUCIS , COMP/OP AGG
32,000,000
s2 000.000
1i,1t2023 'l2l'lDo21
$
COIXERCIAL GEI{EFAL LIABLITY
G€N'L AGGREGATE LIMITAPPLIES PER
E55"t E.o"
xI
POUCY
OTHER:
9520049457
BODILY TiUURY (PF dds't)
AODILY IiUURY (Pd F.$)
E LIMIT6t212024
i40,000
s
s
120,000
ovtl{Eo
AUTOS ONLY
HIREO
AUTOS OIIY
SCHEOULED
AUIOS
NONOIM{EO
AUTOS ONIY
AUTOTOBILE LjABITITY MCA1002609 6122023
I
$
$
EACH OCCURRENCE
AGGREGATE
$
X PER
SIATU TE
OTH,
ER
E L EACH ACCIOENT I1,000,000
TYORXERS COIPEI|SATTOiI
A'{D ETPLOYERS' IIASIITY
ANYPROPRIETOR/PARTNEF'EXECUIIVE
OFFICER/MEMBEREXCTUDED?
DFSCRIPTION OF OPERATIONS b€.d
!\icvo1 420405c 12t1t2023 12t4t202!
Et OISEASF EA EMPIOYFF
E L OISEASE. POLICY LIMIT
i 1,000,000
c 1,000.000
CERTIFICATE HOLDER CANCELLATION
SHOULD AI{Y OF THE ABOVE OESCRIBED POLICIES BE CA CELLED BEFORETHE EXPIRATIOTI DAIE THEREOF, }{OTICE ffLL BE DELIVEREO ITaccoRoANcE wlrH I{E pOLtCy pROVtglOr{S.
Display Purposes Only
o 1988-201s AcoRD coTho ACORD name and logo are rBgistsred marks ofACORDACORD 25 (2016/03)RFORAnON. All rights r€served
CERTIFTCATE OF LIABILITY INSURANCE
INSURER(sI AF'ORONG COVERAGE
DrsuRER A: Arbella Protedion lnsurance Co 41360
ri/suRER B : Merchants Mutual lnsurance companY 23329
DtsuRER C: Atlantic charter lnsurance comDany 44326
X
OCCUR
t 1,000,000
x x
B
UTBRELLAUAE
EXCESS UAA
occuR
E
O€SCRPnON Or OPEiAT|O S / LOGATIOiIS, VEHICLES IACORO 1Ol, Ad.lhlorxl Rm.rb S.n di.. rh.y b. .nsl. d|l l|E6.p.c. lt r.qurd)
AUTHORIZED REPRESENIANVE//