Loading...
HomeMy WebLinkAboutWC Affidavit The Commonwealth of Massachusetts 99 oGl)H.Qii Department of Industrial Accidents Office of Investigations Lafayette City Center W 3 2 Avenue de Lafayette,Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/OrganizationMdividual): \L.L P RO (,R 0)P Address: 9 M R‘ City/State/Zip: CO RED\ n A Lt Phone#: 508 0 4 09 4 C, Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4.El I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New❑ construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. ElDemolition working for me in any capacity. employees and hive workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance. required.] 5.❑ We are a corporation and its 10.0 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 12.01 Roof repairs insurance required.]t c.152,§1(4),and we have no . employees.[No workers' 13.❑Other <,t p 1 N 1, 4U p\AlVital c comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors 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: P e O G Q 6 S S(U E P 01 6 NO P.G 1)A(-b l</ 6-6, Policy#or Self-ins.Lie.#: PG Rqt 13 O b k 6 6 0- PiLWC6 0 119 y Expiration Date::/(..�41 Job Site Address:_/ © (c{/et-( Q r,,� :Jr4 City/State/Zip /oc c�t�("L O2G G Cr 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 insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: &1111ADw>�J�il Date: oSiZ 1J6 Phone#: Cul 09'1'7 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): I 1 1❑Board of Health 2❑Building Department 3EICity/Town Clerk 4.1:Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person:_ Phone#: