HomeMy WebLinkAboutMiscellaneous - Exception (352)QThe Commonwealth of Massachusetts
Department of /ndustr-ial Accidents
Office of Investigations
Boston, Mass. 02111
workers' Compensation Insurance Affidavit
Please Print
Name:
Location:
City Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
1 am an
Faiture to secure coverage as
and/or one years' imprisonmei
understand, that a copy of this
providing workers' compensation for my employees working on this job.
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170_ tot j2 y )
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alu1nnalpenames ar•atine upto$1,500,M
�s.ct%nl..penafties.in.fheJDrmnfa.STOPWORK_ORDER,and_ofine:of.($lAM-00)..a fayagainst.me. I
may be forwarded to the Office of Investigations of the DIA for coverage verication.
and penalties of perjury that the information provided above is true and cormr:t
do not write in this area to be completed by city or town official'
City. or Town
Permit/Licensin
❑ I] Building DeptCheck if immediate response is required Q
Licensing Board
Contact person: [] Selectman's Office
Phone #. F� Health Department
F-1 Other