HomeMy WebLinkAboutMiscellaneous - 20 Home Streetr,a
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The Commonwealth of Massachusetts
Department of Xndustrial.Aeci ents
M - F' 1 Congress Street, Suite 100
Boston, PfA 1 02114-2 017
�c www mass.gov/dia ,
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o kers' Compensation Insurance Affidavit: BuiXdexs/Contractors/Electricians/Pluxnbers.
Workers
TO BE FILED WITH THE pF M(TTING AUTHOf2TTY.
Pleas Paint I,e' 'Tel'
A ' licant Informaiaon t3'
Name (Business/Organizati'oi/iiidivadual):
Address: 2-&
City/State/Zip:.
Phone #:
re you an employer? Checktlie appropriatebox:
,A
1. I am a employer with 1 employees (full and/or part time).
2. Iain a sole proprietor or partnership and have no employees working forme in
any capacity. jNoworkers' comp. insurance required.]
3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t
<1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
s a tca,•
proprietors with no employees,,
5,❑ I am a general contracto a�aud I. have hired the sub -contractors listed onthe attached sheet.
,,
W These sub-contracioks employees and have workers' comp. insurance.
6,❑ We are a cc
152, §1(4),
*Any applicant that
Homeowners who
TContractors that ch
Ve exercised their right of exemption per MGL c.
INo workers' comp. insurance required.]
Type of project
(0 M) .
7. [] Ner`�i`construcilon
8. [] Remodeling
9. ❑ Demolition.
10 [] Building addition
11.[] Electrical repairs or additions
12. �� 'Plumbing rep*dr additions
13:0. Ro6f repairs
14.Cl Other
miffs$ also fill out the section below showing their workers' compensationpolicy information:
fidapit indicating they are doing allwork andthen hire outside contractors must submit a new affidavit indicating such
fname of the sub -contractors and sta%whether or pot those entities have
attached an additional sheet showing the
employees. IfLuc; have employees, they must provide their workers' comp. policy number.
compensation insurance for° my employees. Below is the policy and jo$ site
X am an employer tliat is providingworkers'
information. &-ac,
Insurance Company Name: `'er?- , n�
Expiration Date:
Policy # or Self -ins. Lic. #:
City/State/Zip:
Job Site Address:
Attach a copy of the workers' co�enwsationpoli&ydeel[araflon page (showing the policy numiber and exp�irati�on date).
Failure to secure coverage as require
under MGL o.152, §25A is a criminal violation punishable by 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. A copy of this statement maybe forwarded to the Office of Investigations of the DTA for insurance
coverage vexifica ' • n. •
coverage
here1doby c til un er the ai d penalties oS-11-16
f perjury that the information provided above is true and correct:
11 nn+,.. /It — 16
Official use only. Do not write in this area, to he completed by city or town official
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Ifealth 2. Building Department 3. city/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone
It
Information and Instructions
Massachusetts General Laws chapter 152 requires all emplbyers to provide workers' compensation for their' oyees:
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract odii're,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enferprise, and including the legal representatives of a deceased employer, or the
receiver'd� trusted dan individual, partnership, association or other legal entity, employing employees.. However the
owner of a dwelling House having not more than three apartments and who resides therein, or the ocoiip & of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dvvellirig house
or on the grounds or building appurtenant thereto shall not because of such employment b6 deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withholdthe issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant•whd; has not produced -acceptable evidence of compliance with the insurance coverage requited "
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Additionally, MGL clapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements ofthis chapter have been.presented to the contracting authority."
Applicants
Pleasb fill out the;workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub=contractor(s) name(s), address(es) and phone number(s) along with their certiflcate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. .Also be sure to sign and date the affidavit. The .AV4vit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Iudustrial,Accidenis. Should you have any questions regarding the law or if you axe required to obtain a workers'
compensation policy, piease call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line. -
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (ifnecessary) and under "fob Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each
year. Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT requited to complete this affidavit.
The Department's address, telephone and flax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia