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Home My WebLink AboutCertificate of Insurance - BLDX-24-102 36585s-\The Commonwealth of Massachusetts Department of Industial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 \\:orkers' Compensation rn,".".""'#f;frf,,t;{?rl!.!;'Ja",rr^.r"rs/Electriciars/prumbers. TO BE FILED WITH TEE PERIUITTiNG .A.TITHORITY. ApDlicant Info rma tion Please Print Legiblv Name (Busin esyOrganization/ind.ividual) I u Address: Hrl H S*eu_R]-> CirylStatelZip.U\\^Phone #: ry7| ' 313 -a 77 q2- applicant lha! checkl box f I must also fill out thc scction bclow showing lhcir workels,co Epcnsation policy informatiorrTHomeowncrs who submit this aftrdavit indicating they are doing all work and thcn hirc ouEjde conE-actors must submit a new affidavit indicating suct!tonE-adors that chcck this box must atachcd an additional shcci showing thc narne of the sub-contractoE and state whcther or bot thosc cntitics bavcemployees. lfthc sub-conE_acto6 havc employccs, thcy Eust providc rheir *orkcrs'comp. policy 'lu6ber Arr you r0 .mploycr? Ch.cL th. eppropriat. bor: l.! I am a employer with _cmployecs (full and/or pan-timc).* l.EI I am a solc proprietor or paftrership and havc no cmployees wo.king for me in any capacity. [No workcrs' comp. insurance required.] I am a homeowner doing all work myself [No worken'comp. insurance required.] r I am a homeowncr and wiil bc hiring contractoE to corduct all work on my property ensurc that a.ll coDFacrors eithcr havc workcrs' compcnsation insurance or are soleproprictoE witi no .mployccs. 5.! t am a gcncral conEactor and I havc hircd thc sub-conE-actors listad on trc attachcd sheclThcsa suEconEactgls havc cmployecs and havr workcls' coElp. insurarca.t 6.! We are a corporation ard ils officers have cxcrciscd thcir right ofexcmption per MGL c. I j2, S I (4), and wc havc no cmployecs. [No workas' comp. irlsuraocr rEguired.] l I will Policy # or Self-ins. Lic. #Expiration Date Job Site Ad&ess: City/Statdzip Attach a copy ofthe workers' compensation policy declaration page (showing the policy number and expiration date). 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 WORK ORDER and a fine oiup to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of hvestigations ofthe DIA for insurance coverage verification. I do hereby undet e and. penalties erjury thal the inJormation prot'id.ed aboye is trud and correcl0 S ature: P ne #: Date:'z ,3 -3t3-- 7?? Offrcial use only. Do not wrtte in thb area, to be completed by city or town ofJicial City or Town: .- permiUlicense # Issuing Authority (circle one): l. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing lnspector 6. Other Phone #:Contact Person: UAot t;f Type of project (required): 7. f] New construction 8. ffiRemodeling 9. E Demolition l0 L_l Burldrng addrtron 1l.f] Electrical repairs or additions 12. ! Plumbing repairs or additions 13. fl Roof repairs l4.nOther_.-._=_.-- I an an enployer thd b Ptoviding t'orken' conqtensation insurancefor my enqtoyees. Below is the policy q.n(ljob siteinlornotion- Insurance Compa.ny Name:_ ^ifu COVERAGES CERTIFICATE OF LIABILITY !NSURANCE CERTIFICATE NUMBER REVISION NUMBER: OA'E (N'DqYYYY) o).12312024 THIS CERTIFICATE IS ISSUEO AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENO, EXTEND OR ALTER THE COVERAGE AFFOROED BY THE POLICIES BELOW. TH|S CERTTFICATE OF INSURANCE DOES NOT COiTSTTTUTE A CONTRACT BETWEEN THE TSSUTNG TNSURER(S), AUTHORTEO REPRESET'ITATN'E OR PRODUCER, ANO THE CERTIFICATE HOLDER. IMPORTANT: lflhe certificate holder is an ADDInONAL INSURED, the policy(ies) must have ADOInONAL INSURED provisions or be endorsed. lf SUAROGATION lS wAlVED, subjecl to lhe terms and conditions ol the policy, certain policies may require an endorsdnent. A statement on this certifiaale does not confer rights lo the certificale holder in lieu of such endorsenEnt(s). PiooarcEn BIBERK P.O. Box 113247 Stamford, CI 06911 [tST,lREDMarc Bourgault 47 Haskell Road Plymouth, MA 02360 FY T}IAT IHE POLICIES OF INSI.JRANCE LISTED BELOW FIAVE BEEN ISSUEO TO THE INSURED AIAMED AEIOVE FOR TI€ POUCY PERIODINDICATED- T.IOTWTHSTANDAIG AI.{Y REQUIREMENT, IERM OR CINDITION OF ANY CONTRACT OR OTHER DOCUMENT WIH RESPECT TO WHiCH THIS CERTIFICATE MAY BE ISSUEO OR MAY PERTAIN, IHE INSURAI.ICE AFFORDED BY THE POLICIES DESCRIBED HEREIN lS SUBJECT TO ALL THE TERMS, EXCLUSIOiIS Al.D CO|{OTIONS OF SUCH POUCIES. UMITS SHOlilN MAY HAVE BEEN REOUCED By pAtD CLAjMS. TYPE OF IIISU RANCE THIS IS IO CERll x COUITIERCIAL GENERAT LIABILIIYX tEnIL GREGA UTE T PERES POLiCY JEI x occuRt I]ER N98P537573 PRODUCIS - COlilP/OP AGG 01/2412024 01/ 2412025 lt---r-s s 5,000 2,000,000 50,000 ErcH OCCURRENCE DAMAG€ TO RENIEO !r!Es E9]49s9!€.soO ?E89gl!a g fQYtllgE! GENERAT AGGREGATE Included 2,000,000 AUTOMOEILE LIABILITY SCHEDULEOAUT(\Sllotlolr/tlED AUIO€ ONLY ol/\/NEoAWqS ONLY HIRED AUTOS Or!LY co rl.BoOTLY li(rJRY (Pe. e6klcdl) mOILY lMrrRY (Pe. Frsoa) OAMAGE UUSRALA LIAB EXCESS LlA8 OCCUR cL lrr$MAoE RETENTION $oEo ErcH OCCURRENCE s AGGREGATE 5 ta rcRKERS CflPEi{SATTO{ AXO flPLOYEiS UAEIfi AIiTYPROPRIETOR/PAtrTNER/EIECUTIVE OFFICER/TIEMSER EXCLUDEO?(x.ndabry in xH) OESCRIPTION OF OPERAIIONS b.lo N E L DSEASE, POLICY LIMIT s s $E L DISEASE. EA EM Professional Uability ( Errors & Omissions): Claims-Made Per Occurrence/ Aggregate oEscRlPTloN oF oPEIlalloils, L@aTloNs, \,EtIcLEs la@RD lot, a.tditilt.t Remarts srh.dut€. may b. rttach.d |'lnors spac. 13 Equircd) CERTIFICATE HOLDER CANCELLATION Marc Bourgault 47 Haskell Road Plymouth, MA 02360-AUTHORIZED REPRESENTATIVE t +*'^ 6*.- @ 1988-20i5 ACORO CORPORATION. Alldghts r€served. The ACORO name and logo are ,€glstered marts oIACORDACORD 25 (2016/03) LIMIISPOLICY EFF POLICY EXP I MM/DDIYYYY] $ $ s 1400r0!q fl .o. S 6 S T l tr E L EACH ACCIOEITI SHOULDA'{Y OFTHE AAOVE DESCRIBED POUCIES EECAI'CELLED BEFORETHE EXPIRATIOT{ OATE THEREOF, I{OTICE wlLL BE D€LIVEREO IN ACCORDAI{CE wlTH TXE POLICY PROVI$OllS. I - 7/\ACORiJ CERTIFICATE OF PROPERTY INSURANCE o IE 0ir/Do/rrYY) oLl23l2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMANON ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETVUEEN THE ISSUING INSURER(S), AUTHORIED REPRESENTATIVE OR PROOUCER ANO THE CERTIFICATE HOLDER. BI BERK P.O. Box 113247 Stamford, CT 05911 INSUREO Marc Bourgault 47 Haskell Road Plymouth, MA 02360 COVERAGES CERTIFICATE NUMBER REVISION NUMBER: L@ Ipt{ Of PREIBES I I)€SCEPIpN Of PROPERTY (Aiadr AcoRo io!. Arldlirml R€mut srch.dub. ir nols.p.ce 16 llqlltrcd) LoGtion: 47 Haskell RoadPlymouth, MA 02360 Bldg #O01: Carpentry - 7422l0r tNsS LTF FY TFIAT THE POUCIES OF INSURAiICE USIED BELOW l-i,AVE BEEN ISSUED TO THE INSUREO NAMED ABOVE FOR THE POUCY PERIOD IND{CATED, NDTWTHSTANOTlG AI.IY REQUIREMEI.IT, TERM OR @NDTION OF ANY CONTRACT OR OTI.IER OOCTJMENT WTH RESPECT TO V!}IICH THIS CERNFICATE MAY BE ISSUED OR MAY P€RTAIN, TI.E INSI.,'RANCE AFFORDED BY TIE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERi,gS. EXCLI.ISIOI{S AND CONDTIO}IS OF SUCH POUCIES, LIMITS SHOTAA MAY HAVE BEEN REDUCED BY PAID CLAIMS, POLICYEFFECIIVE POLICYEXARATIONIYPE OF INSIJRATlcE POLICYNTJMBER COVEREOFiOPERIY Lt,rflTSOAIE (I{M'DO'TYYY)OATE (MM/DOIYYYY) THIS IS TO CERTI D€ rc'TIBLES BROAO x CAUS€S OF LOSS BASIC X FLOOD SPECIAL EARTHQUAKE BUILDNG co 250 N98P537573 ou24l2024 01/24/2025 zu!LOrirc PERSONAL PRCIPERTY gusNEss titcoic TRA E{PENSE REI.ITAI VALUE BI-ANKEI AUILOING B(AN(ET PERS PROP BI.ANKET &OG A PP s a nla 0 nla $ 5 CAUSESOF LOSS NAMEDPERILS FOLICY NUMEIER IYPE OF POLICY $ s lt TYPE OF POTICY s E s BOILEF IT MACIIIN€RY I&UPMEI{T BREAXOOWN s s 5 SPECIAL GOillrTlOt{S ' OTHER COVERAOES IACORO rot. AddtoonatR.lnarrs sdt dut.. ma, b. .tbch.d if mor! 3r.c. i. rEquir.d) * ALS up to 12 months. CERTIFICATE HOLOER CANCELLATION SHOULOAT{Y OFTHE ABOVE DESCRIBED POLICIES BE CAI{CELLED BEFORETHE EXPIRATIOT{ DATE THEREOF, I{OTICE WILL BE OELTVERED ItIACCORDAT{CE WTH THE POLICY PROVISIOT{S.Marc Bourgault 47 Haskell Road Plymouth, MA 02360- {-+*'- 6AUTI]ORIZED REPiESENTATIVE {+- o 1995-2015 ACORD CO The ACORD name and logo are reglstercd ma.Is ofACORD RPORATION. AI rights rcserved. rNslrRERls) AFFOROTiTO Co\/EnAOE rBerE!lrg_!11tll1!9y lllgct l!!!ra n!9gFpa I L203 )654-3613 fa I ! s s AcoRD 2/t (2016/03)