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Home My WebLink AboutMiscellaneous - 515 Lowell Street (2) v The Commonwealth of Massachusetts DepartmentoflndustrialAecidents ry 3• M 4 1 Congress Street,Suite 100 4 2017 Boston,IY.GI7.0211 - q�r www mass.gov/die SJ.y a o>hers'Compensation Insurance Affidavit:Bnildex /Contr, yVctors/llectxiciaus/1'lumbers. TO BE FILED WITH TBE PEP MCTTINGAUTHOI2I�S'. ..Blease Print Le" bl- A ''licantXnfoxnuaiatou f.1, Name(Business%Oxgauiz ' ' atioii/lndividual):�/(�40 Address: Ci /State/Zip:PA15X50 /�� /2�� Phone#:ty .Are you an employer?Check the appropriate box: Type of pxoJect(required); ern to ees frill and/or parE time). 7. E]Ne*.'d6nstruclion l fl 1 am a employer with P y 2. 1 am a sole proprietor or partnership and have no employees working forme in $. mo delirig any capacity.(No workers'comp.insurance required.] 9, Demolition 3. I am a homeowner doing all work myself[No workers'comp.insurance required.] 10[]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11 0 Electrical repaizs or additions ensure that all contractors either have workers'compensation insurance or axe sole !a x E� ' j"* 'Plu�abing repair's or addiiion5 proprietors with no employees. 5,❑I am a general contracfg Gaud I have hizedthe sub-contractors listed onthe attached sheet 13; Rb6f repairs N:.. ;y.. These sub-contracts;shave employees and have workers'comp.insurance. 14.0 Other 6. We area coiporatron and its officers have exercised their right of exemption per MGL c. 152,§1(4),and'v,'f e have�rib employees:[No workers'comp.insurance required-] *.4ny applicant that cheoks:box#1 mpst also fill out the section below showing theirworkers'compensationpolicyrnformation Al Homeowners who su6mit;tl9is a da-'t indicating they are doing all work and then hire outside contractors must submit a new affidavit indi ting such �; tContractors that check4 Uox must attached an additional sheet showing the name of the sub-contractors and state whether of not(hose.enti'es have employees. If the sub conixactors have employees,they must provide their workers'comp.policy number. t s- - mpensation insurance for my employees. Below is the policy and job site X am an employer that is providing-Workers'co information. + Insurance Company Name: //rZ3P�/' Expiration Date: 5 - Policy#or Self-ins.Lic.#: �� w•'Pl�-� p 93 Job Site Address: �2Ue/C/(/ &Cry I ��U/9 D City/State/Zip:�L�1, Attach a copy of theW' 17kers'compensation policy declaration page(showing the policy number and expiration date). by a ffib up to$1,500-00 Failure to secure coverage as required under MGL a. es i the§25f is aocf a STOP al iWORK ORDER olation punishable nd a fine of up to $250.00 a and/or one-year'imprisonanent,as well as civil penalties in the form be forwarded to the Office of Investigations of the DIA for insurance day against the violator.A copy of this statement may coverage verification. Ido hereby certify n e tl ailas and p aIdes ofperjury that the information provided above is trit. true and correct Date: 3 Si ature: Phone#: 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): i 1.Board of gealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone Contact Person' #• i Information and Instructions Massachusetts General Laws chapter 152 requites all employers to provide workers'compensation for their employ es: Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract o£liixe; express or implied,oral or written." An employer is d'efnied as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver"8irtrustee peau indivi4ual,partnership,association or other legal entity,employing emplbyeeg.-However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant'of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling 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 withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant•wlioih'as:notp�roduced-acceptable evidence of compliancewith the insurance coverage ieequiired." gait•-.,e Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been,presented to the contracting authority." .applicants Please 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 affir�avit.should be returned to the city or town that the application for the permit or license is being requested,not the Department of IndustrialAccidenis. Should you have any questions regarding the law or if you are required to obtain a work exs' ` F.. compensatiofi policy,please 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 PIease 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"rob 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. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license orpermit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax 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-MA.SSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia