WORKERS COMP 2025The Common wealth of Massachusetts
Department oflndustrialAccjdents
Office ofIn vestigations
Lafayette City Center
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/OrganizationJjndividual):SUNSHINE SIGN CO.INC.
Address:121 WESTBORO RD.
City/State/Zip:GRAFTON MA.01536 Phone #:508-839-5588
Are you an employer?Check the appropriate box:
I.Eli I am a employer with 34 ~•U I am a general contractor and I
employees (full and/or part~time).*have hired the sub-contractors
2.El i am a sole proprietor or partner-listed on the attached sheet.
ship and have no employees These sub-contractors have
working for me in any capacity.employees and have workers’
[No workers’comp.insurance comp.insurance.:
required.]5.fl We are a corporation and its
3.El I am a homeowner doing all work officers have exercised their
myself.[No workers’comp.right of exemption per MGL
insurance required.]t c.152,§1(4),and we have no
employees.[No workers’____________________
comp.insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers’compensation policy information.
t Homeo~~~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 ant an employer that is providing workers’compensation insurance for my employees.Below is the policy and job site
information.
Insurance Company Name:SELECTIVE INS.CO.OF AMERICA
Policy #or Self-ins.Lic.#:WC9097339 Expiration Date:9/19/2025
Job Site Address:_______________________________________________________City/State/Zip:_________________________
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 ofperjury that the information provided above is true and correct.
Si~a~re:~~Date:9/26/2024
Phone #:508-839-5588
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):
lDBoard of Health 20 Building Department 3UCity/Town Clerk 4.0 Electrical Inspector SElPlumbing
Inspector 6.QOther _______________________________
Contact Person:__________________________________________Phone #:
Type of project (required):
6.El New construction
7.El Remodeling
8.El Demolition
9.El Building addition
10.0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.0 Roof repairs
13.0 Other_____________________