HomeMy WebLinkAboutWorkers Comp 10/30/26 The Commonwealth of Massachusetts
Department of IrzdustrialAccidents
POffice of Investigations -
.. . lik, Lafayette City Center •
C 2 Avenue de Lafayette, Boston MA 02 - 5 z�z z7 0
V^Stir www.mass.gov/dal
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumb ers
' Applicant Information Please Print Legibly
Name (Business/Organi7ationandividua1): efrn-viii /314l /fi ll G.e f$,SQL/ --e-s
Address: r C l
City/State/Zip: S' !a` fi - Phone#: (.5.- f) L 1 ^ 7'9?
Are you an employer? Check the appropriate box: Type of project(required):
1.I I I am a employer with 4. I( I am a general contractor and I
employees (full and/or part time).
I 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. n Demolition
working for the in any capacity. employees and have workers'
cam insurance.t 9. `Mtn ding addition
[No workers' comp.insurance p
required.] 5. n We are a corporation and its 104 I Electrical repairs or additions
3.n I am a homeowner doing all work officers have exercised their 11_n Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12 n Roof rep airs .
insurance regnired,J t c. 152, §1(4), and we have no
employees. [No workers' 13.1 (Other
comp.insurance required.] .
*Any applicantthat checks box#1 must also-Fill out the section below showing their workers'comp ensationpolicy information.
f Homeowners who submit this affidavitindicating they are doing all work andthen hire outside contractors must submit a new afftdavitindicating 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.p olicy nomber.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 3 i r V `lam
•
Policy#or Self-ins. Lic.#: /Y is 8P ''73 (91 Expiration Date: Cr/`I /7----7
Sob Site Address: Z 5tt/1/1/ irn/frf City/State/Zip: W �Ci
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 fatal 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.cer ' under the pains an. ,- Tries ofperjury that the information provided above is true and cor ect
Signature: QDate: /v/?'f Z fo
Phone#: .
Official use only. Do not write in this area, to be completed by.city Or town official,
City or Town; Permit/License#
Issrting Authority(check one):
1nBoard of Health 20 Building D epartment 3fiCity/Town Clerk 4.l Electrical hasp ector 5.aluxnbing
Inspector 6. tOther
Contact Person: • Phone#: