HomeMy WebLinkAboutCertificate of Insurance - BLDX-24-88 35918:b-\The Commonwealth of Massachusetts
D ep artme nl of I n d ustrial A ccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
trww.mass.gov/dia
\Vorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers-
TO BE FILED WITH THE PERTVIITTING .{LITHOzuTY.
0 rma t e bt
Name (BusiDess'Organization/ladividual)flV-,a,t 4,. t-'t// /, Hrb /
Address:/. eg a4nn, ez
Cily/Stztelzip:r.zt
* Any appl icant that checks boxt Houreo*.nen -,,'rho submit this
tconaactors that chcck this box
/4,/ oztzz Phone#: ,5V ?772-?2e(
Type of project (required)
n
New construction
Remodeling
Demolition
Building addition
Electrical repairs or additions
Plumbing repairs or additions
Roofrepairs
other rfurO/.s A O) I aar
7.
8.
9.
10
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12
13
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#1 must also fill out the sectioo below showing their workers' compensation policy infomatio[
afEdavi! indicating they aae doing all work and then hire ouBide contractols must submit a new afidavi! indicaing such.
must attachcd an additional sheet showing the [amc of the sub-contnctors and state whether or not those entities have
employees. lf thc su[conllacto$ have employees, they rousr providc thei! wo.kers' comp. policy nullber
Ar. you an employ.r? Chcck the .ppropriatc bor:
I.! I am a employer witir cmployees (frrll and,/or part-timc).*
2@l ar, a sole proprietor or paroership and have no employees working for mc in
any capacity. [No worlicrs' comp. insurance requircd_]
I am a homeowner doing all work myself. [No worke6' comp. insurance .equired.] i
I am a homcoqr.er and wiil be hiring contra.tors to conduct a.ll work on .fly propelry. I wiil
cnsurc that all conE_aclors eithcr havc woakets' compcnsation tns1rraace oa ate sole
proprictors widl no coployees.
I am a gencral cont'aclor and I havc hired the sub-coo!'actors list.d on the attachcd sheet.
These sub-conEactpB have cmployees and have workcrs, comp. insruance.l
Wc arc a corpor"lion a.nd its officers have cxercised their right ofexemption pcr MGL c.
152, S I (4), and we have no employees. [No workers' comp. insu-ance rEquircd-]
,t
5
I am an employer that ts providing workers' conpensation insurance for my employees- Below is the polic! and job site
infornwton-
Insurance Company Name::qr
Policy # or Seif-ins. Lic. #
Job Site Ad&ess: 42J /ro- ,4,
Expiration Date
Ci!v/State/Zip ZZ
Attach a copy ofthe workers' compensation policy declaration page (showing the policy ber and exp ation date).
Failure to secure cover€e as required under MGL c. 152, $25A is a criminal violation punishable by a fine up to $1,500.00
and.ior one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine ofup to $250.00 aday against the violator. A copy ofthis statement may be forwarded to the ofEce of Investigations ofthe DIA for insurance
coverage verification.
I do hereby certify 4te pa.ins andpenalties ofperjury that the information provided aboye is trud and. correcL
S Dat /
P one #E-- >2a-z
al use only. Do not wtite in this areo, to be completed b! cit! or town offi.cial.
Issuing Authority (circle one):
1- Board of Health 2. Building Department 3. City/Tor n Clerk6. Other 4. Electrical I[spector 5. Plumbing Inspector
Photre #:
offici
City or Townr
Contact Person:
_PermiVliceuse#