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HomeMy WebLinkAboutMiscellaneous - Exception (208)Department, of 'lndustrial Accidents Office of Investigations X Congress Street, Suite 100 Boston, AM 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): A % !r J ( © j? yz)Tf L Address: 1_ - Oy,�, k S i -e_ ilcoj Phone #: /' 97) k-'�S " 5 �'' 2 15 3 Are you an employer? Check the appropriate bog: 1.2 I am a employer with .3 4. ❑ I am a general contractor and I employees (full and/or part-time).* have;hired the sub -contractors 2. ❑ 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. ❑ We are a corporation and its 3. ❑ 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' comb. insurance reouired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. [M Other ) ST 6 TV g 0 1.,LV 11" *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. #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 tleir workers' comp. policy number. I am an employer that isproviding workers' compensation insurance for my employees Below is the policy and job site information. kke //4YJ Insurance Company Name: T Policy # or Self -ins. Lie. #:Alis RAL) 0 C_� 7> d Expiration Date: 3/d y Job Site Address: `tD City/State/Zip: NOV kk AfbWl /W l 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. Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature:Date �) �) - � Phone #: �' % 7 3 2 f '5 3 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City%Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #•