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Home My WebLink AboutWorkers Comp 2026 s;_ ORKERS'COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY \---------- -— INFORMATION PAGE £-v �( m. 0 � � Associated Employers Insurance Company(500) fi 54 Third Avenue,Burlington,MA 01803-0970 --✓-- ! (800)876-2765 H;.;!LJItJ.` � �" NT j \...._ —. NCCI NO: 40959 Policy No. WCC-500-5024303-2026A Prior Policy No. ITEM 1. The Insured: Baxter Innkeeping LLC DBA: Chapter House Cape Cod a/o Baxter Yarmouthport Mailing Address: Holdings LLC FEIN: *****0520 PO Box 1503 East Dennis,MA 02641 Legal Entity Type: Limited Liability Company(LLC) Other workplaces not shown above: See Location 2. The policy period is from:02/11/2026 To 02/11/2027 12:01 a.m.at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance:Part Two of the policy applies to work in each state listed in Item 3.A.The limits of our liability under Part Two are: Bodily Injury by Accident $500,000 each accident Bodily Injury by Disease $500,000 policy limit Bodily Injury by Disease $500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states,if any, listed here: Coverage Replaced by Endorsement WC 20 03 06 B D. This policy includes these endorsements and schedules:SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans.All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Total Estimated Per Estimated No Annual $100 of Annual Remuneration Remuneration Premium INTRA:001194667 SEE CLASS CODE SCHEDULE INTER: Minimum Premium:$267 Total Estimated Annual Premium: $2,099 GOV GOV Deposit Premium: $545 STATE CLASS MA 9052 State Assessments/Surcharge: $78 /7 This policy,including all endorsements,is hereby countersigned by / 12/26/2025 Authorized Signature Date Service Office: P.O.Box 4070 Agency: The Hilb Group of New England LLC— Burlington,MA 01803-0970 973 IYANNOUGH ROAD HYANNIS,MA 02601 WC 00 00 01 A(Ed.7-11) Includes copyrighted material of the National Council on Compensation Insurance,Inc.,used with its permission. Page 1 of 1 ��\ The Commonwealth of Massachusetts ' Department of Industrial Accidents __,1,,-, . Office of Investigations =;v i= Lafayette City Center �, 1--. -y "�J 2 Avenue de Lafayette, Boston, MA 02111-1750 r, www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 461) 7-42. 4/kRi ,4 / (-Le a (fh*P 72- f'V Address: 2`T 7 W(L 4 4- r `� 026It City/State/Zip: /,41'l Cl/ PPu�.�}(-(9fr Phone #: 310 e 7 7 $/L Are you an employer? Check the appropriate box: Type of project(required): 1.Erlyam a employer with 7 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0Roof repairs insurance required.] I. c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I.Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. . ' Insurance Company Name: �5l fO e/4 2 b tfrl/aC 0/ids tN.ft/12.l4/✓C E Co Policy#or Self-ins. Lic. #: ‘doG - fO--0 -) O Z 9/ 03' Expiration Date: - t /Z7 17f 2?1. ‘4/ Y�4 iOd M2 t— Job Site Address: City/State/Zip: ./-1A._ O 6 1,-7 I Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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 of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for in ance coverage verification. I do hereby certify under th ns and penalties of perjury that the information provided abo'e is tru and correct. Signature: �1 Date: / e d /7-02- 6 Phone#: — 5l D 571 5TIV. Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 1❑Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5.0Plumbing Inspector 6.0Other Contact Person: Phone#: