3-18-2025 Pro Sign Sunoco 145 Canal Street Salem MA WC Affidavit S�" The Commonwealth of Massachusetts
Department of Industrial Accidents
` Office of litvestigations
Lafayette City Center
�l 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): Pro Sign Company
Address: 251 Boot Road
City/State/Zip:Downingtown PA 19335 Phone #: 610-518-5881
Are you an employer? Check the appropriate box: Type of project(required):
1.21 1 am a employer with 60 4. ❑ I am a general contractor and I
employees (full and/or part-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 g, ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp.insurance comp. insurance.t 9• ❑Building addition
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their l l.❑Plumbing repairs or additions
myself No workers' comp. right of exemption per MGL
y [ 12.❑Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.® Other Signa�e
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1Contractors 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: Utica National Insurance Company Ohio
Policy#or Self-ins. Lic. #: 5383095 Expiration Date: 12/19/2025
Job Site Address: _ � /(� ..51,�?AGe/0]—City/State/Zip: C5�q
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 forni 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 andpenalties of perjujy that the information provided above is true and correct.
Si=unature: jesslGa Daylf Date:3/10/2025
Phone#: 484-576-7599
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):
1❑Board of Health 20 Building Department 3E]City/Town Clerk 4.0 Electrical Inspector 50Plumbing
Inspector 6.❑Other
Contact Person: Phone#: