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Department of Industrial Accidents
Office of investigations
I Congress Street, Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aip2licant Information Please Print Le Ll
Name (Business/OrganizatioaIndividual):`rim MCMU,.-it V. p% Y S NS
Address: jwit> 1MA
CitylState/Zi 0 Phone#: " 7 _
Are you an employer? Check the appropriate box:
1 ❑ I am a employer with 4. Q I am a general contractor and I Type of project(required):
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. T Q Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity, employees and have workers'
[No workers' comp.insurance comp.insurance.; 9. [}Building addition
requite.] 5. ❑ We are a corporation and its IO.[]Electrical repairs or additions
3.❑ I am a homeowner doing all wort; officers have exercised their I LE]Plumbing repairs or additions
myself. [No workers' comp, right of exemption per MGL 12.Q Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees, [No workers' 13.[9 Other s�
comp.insurance required.]
*Any appticant thatebeekc box#i must also fill out the section below showing their workers'compensation policy information.
t Hommwners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractora that check this box must attached an additional sheet showing the name of the subcontractors and state Miether or not those entities have
unploym, If the sub-caatrac►ors have employees,they must provide their workers'comp.policy number.
I am an employer that is protvding workers'compensation insurance jar my employees. Below is the policy and job site
informatian.
Insurance Company Name:
Policy#or Self-ins. Lic.#: Expiration Date:
.lob 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 S11,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of tap to$230.00 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 c9d
k
gloer the ins end pen s of per'ury that the information provided above is true and correct.
S. tore: ✓ Date:
Phone ►—
Offi ial use only, Do not write in this area,to be completed by cin,or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.13uilding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
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