el poblano_workers comp affidavit (1) The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
--.; Lafayette City Center
2Avenue 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/Organization/Individual):Signverse, LLC _
Address:24 Spencer Street
City/State/Zip:Stoneham, MA 02180 Phone #:781-438-5280
Are you an employer? Check the appropriate box: Type of project(required):
1.0 I am a employer with 5 4. ❑ 1 am a general contractor and I
employees (full and/or part-time).
* have hired the sub-contractors 6. ❑New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have $, ❑Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance.1
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 I l.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §Sl(4), and we have no Si ns
employees. [No workers' 13.0 Other g
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
1 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:The Hartford
Policy#or Self-ins. Lic. #:08WECACOJ K4 Expiration Date:09/15/2025
Job Site Address: 105 Lafayette Street City/State/Zip:Salem, MA 01970
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 certr:fyn e pains and penalties of perjury that the information provided above is true and correct.
aim,ure: Date: 05/16/2025
Phone#: 781-438-5280
Official ttse 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 30City/Town Clerk 4.0 Electrical Inspector 50Plumbing
Inspector 6.❑Other
Contact Person: Phone#: