HomeMy WebLinkAboutCertificate of Insurance - BLDX-24-28 33077The Commonwealth of Massachusetts
D ep art me nt olt I ndustrial A c c identsI Congress Street, Suite 100
Boston, MA 02114-2017
www. mass.gov/dia
\\:orkers' Compensatio,. Insurance Affidavit; Builders,/Contracto rs/EI ectricia ns/p lum bers
TO BE FILED WITH TIIE PEfIVIITTING .{TITHORITY.t 0rm ease Print
Name (BusinesvQrganization/tndividu^Dt Plts'\eta^W P-t-louvq,e-S
Address: )3 )&FPr6 Dt*.re
Arc you an employer? Chcck the approprirte bor:
l.! I am a employer with _employees (full and/or part-time).*
am a sole proprietor or parmership and have no employees worki
any capaciry. [No workers' comp. insurance required.]
ng for me in
l I am a homeourier doing all work myself [No workers, comp. insurance required ] i
I am a homeowncr and will be hiring contractors to conduct a.ll work on my propeft/
ensure that all contractors either havc workqs, compensation itsuraace or are soie
proprietors v,/ith no coployces.
5.! I am a geoeral conEacror and I havc hircd the slb-conE-actors listed on the attached sheet.
These sub-conEactgrs have employces and havc workcrs, comp. insuralce.l
6.! We are a corporation and its officers have exercised theia right ofexemplon per MGL c.
152. $l(4), and we have no employees. [\1o workers, comp. insurance required ]
Iwill
Ciiy/StatelZip:>€il^J rS rqA- odCBO phone#: . 3)8->%.g,lfr
rAny applicant that checks box #l must also fill out thc section below showing their workcrs' compensatjon policy info.matiorlT Homeowners who submit this affidavit indi caong they are doing all work and then hire ouBide coDtractors must submit a new affidavit indicati€ sush.tcontactors that chcck this box crust attached an additional sheet showing thc oame ofthe sub-conE-actors and state whether oa not those cntities haveemployecs. If the su[cooE-actors have employees, they must provide their worl<ers'comp. potiry nuurber
I afi an emPloler that ts providing workers' compensation insurance for my employees- Betow is the po\cy and.job siteinfomwtion.
Insura.nce Company Name:
Policy # or Seif-ins. Lic. #:Expimtion Date
Job Site Address: City/State/Zip:Attach a copy ofthe workers' compensation poli.y a.Jr.xioo !rg. Iuotuirg il. poti"y nr*u". ,na .*pirrtioo axq.
Failure to secure coverage as required under MGL c. 152, $25A is a criminal violation punishable by a fine up to $ I,500.00and'/or one-year imprisonment, as well as civii penalties in the form of a STop woRK oRDER anja hne 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.
Ido
P ne
hereby certily under the ains and penahies of pe4ury that the inlormation provid.ed above is hud and cofiect.
Date: l'q'>e
5d?,. go 9iLt
, Do not write in this area, to be completed b! cifii or town ofJicial.
Issuing Authority (circle one):l. Board of Health Z. Building Department 3. City/Town Clerk6. Other 4. Electrical Inspector 5. plumbing Inspector
Phoue #:
OfJicial use only
City or Town:
Contact Person:
I
Type of project (required):
7. I New construction
8. ! Remodeling
9. Li Demolrtron
l0 E Building addition
I l.E Electical repairs or additions
12. I Plumbing repairs or additions
13. fl Roof repairs
l4.Ioth"'-SJDtl4Z44