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Project Type: ❑New Conshuction ORemodel ❑ 7 arn a sole-propridor and have no�e wockiog in�y capacity. ❑Bwlding Addition (�[am an�npbyer providing wcekas'wmpeasaji�for my anpbyees wodcing�Nds job. ��.�• fl��f�s� 1�-,�, �q .�t�� -_ _ .�..- �ty- �K: U.�7�0lp. �� �..t �r w �S-ts�rr-6.s �. r.',*rs .,a<dYL+9@�'w,.� ❑ I am a sole proprietor.gaeral coatracter,or 4omeawwer(drde om)md have hirod tl�e�[as listed below w6o have�. the folbwing workas'compensation polices: �� . . sQswav�me: aaarm-� . . . . . � . . . . . � . . . � . dh: � . , - . . . . . �F: � .. . . , � . . . inea�oe a. p��g - , ,.z .�mrv�=. , :,. -��. . .�,_. . . . .. . :.;. . � .,�. ... ,�„� xxg;cg.rF;w. OOOYV�!: i�tl5: CIq[. ... � : . . . . . . . . OYl�!/- . .. . . � . , . . ��p)�FIYt�1a�l�ltlJblfNwarAdbNlOmmd ...�"�"'..••..w..�..u�sa>aw.wa.ryayroc�G. �YCeKa�dWt■ � 1neMinlMmNlYeDlAire�ve'aae�eipntlN, - � . /!e Aereby ceretjy rndern6e peh�a awd penahlea eJperlwy'Mer Me Iwlaairleu Provided ebaae la ave wd osrrkt� . . 3ig�um Priot name � . .. . . . . - . . Phone# � � � .�I.xa�y a.r.�sarw...e.weie.pekasri*r.ry�.�. . � . . .. cNyor bw�. .p�e E Il�.rs.�p�� . ❑eYeck If f�de�le reepwe 6 Rq�M�ed � - . � � � � . .. �Bau�A Q4dccl�eS Omee . cn+:N� pWeW. .. . . � �� . ' • �,e � ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY RENEWAL QUOTATION WORKERS' COMPENSATION PLEASE MAKE REMITTANCE T TEL.# (800) 876-2765 A.I.M.Mutual Insurance Co Da[e Ol/O6/2009 P.O.eox 4070 Burlington,MA 01803-0970 Gaytri Krupa Corp IMPORTANT: COVERAGE WILI NOT BECOME dba ualily Inn&Suites EFFECTIVE UNTIL YOUR POLICY EFFECTIVE . 1314 oute 728 DATE. Sou1h Yartnouth,MA 02664 PLEASE PAY THE TOTAL AMOUNT DUE SHOWN BELOW NO LATER THAN: INSURED OZI��IZOO9 J J Gilmartin&Son Agency Inc 1293 Post Road � � Warwick,RI 02888 VRODUCEROFRECORD y�� ...----_'�`___"' — Policy EffeMive Date 03/09I2009 � Policy Number VWC 6008047012009 Rates Per Eslimated Ann emiums CODE Annual NO. Remuneration Remun- Subject to eratlon Modification AllOther - SEE EXTENSION OF INFORMATION PAGE TOTAL ESTIMATED ANNUALPREMIUM eeo TOTAL MA ASSESSMENT 683 x 6.3000% 43 DEPOSIT PREMIUM sso DEPOSIT ASSESSMENT 43 nlafauci TOTALAMOUNT bUE i, 003' , . FOR COMPANY USE ONr�LY Net Amount of Check � � � S , U� ' Initial&Date l D placing oflice: 604 AP 4921 (9-89) ,