64 Grove Street Workmans Comp_Page_1 The Commonwealth of Massachusetts
Department oflndusirialAccidents
Ogice of Investigations
Lafayette o Center
B
2Avenue de Lafayette, Boston, MA 02II7-7750
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Li ibly
Name (easiness/ocganizaeon/mdividual): Batten Bros., INC
Address: 893 Main Street
City/State/Zip:Wakefield, Mass 01880 Phone #: 781-245-4800
Are you an employer?Check the appropriate box: Type of project(required):
1.X I am a employer with 15 4. ❑ I am a general contractor and I
employees (bill and/orpart-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 S. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp. insurance comp. insurances
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' cc
mp. right of exemption per MGL 12.❑Roofrepairs
insurance re c. 152, §1(4),and we have no
required.] t] employees. [No workers' 13. Other Signs
comp. insurance required.]
*Any applicantthat checks box#1 most also fill out the section below showing their workers' mmpensationpolicy information
T Homeowners who submit this affidavit mdicatmgmey are doing all work and then hire outside contractors most submita new affidavit indicating such.
sContractors that check this box most attached an additional sheet showing the name ofthe mb-contractors and state whether ornot those entities have
employees. Iftheme contractors have employees,they mostprovide their workers'comp policy number.
Imnanemployertlud isprwidingworkers'coWematioxin� eformy employees. Belowisthepolkymedjobsde
information.
Insurance Company Name: Pinnacle Point Insurance Company
Policy#or Self-ins. Lic. #:WCP7008748 Expiration Date:8/27/26
Job Site Address: 64 Grove Street City/State/zip:Salem MA
Attach a copy ofthe 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
ofup to$250.00 a day against the violator. Be advised that a copy oftlhis statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cei smider the pains muipenalties of perjury that the informationprovided above is true muicorrect
Jeff Sarra rig idly signed aycatSand 09/24/25
Simature: ose 2025.09 m 14 52 08 04 gg Date:
Phone#. 781-245-4800
O„Q➢cial use only. Do not write in axis area to be eomp]etedhy city or[own ofci&
City or Town: Permit/License#
Issuing Authority(check one):
I❑Board of Health 211 Building Department 3❑City/rown Clerk 4.11 Electrical Inspector 501umbing
Inspector 6.❑Other
Contact Person: Phone#: