36-128 (3) - � 2,6
The Commonwealth of Massachusetts
' Department of Industrial Accidents
I Congress Street,Suite 100
Boston,.MA 02114-2017
www mass gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print LeaiblN
Name(Business/Organization/Individual): [ ,sem-°�,, L e c.y z
Address:
City/State/Zip: -*.,,c t t- N Phone `ms
Are you an employer?Check the appropriate box:
Tyke of project(required):
1.0 1 am a employer with employees(full andiorpan-time).` 7. []New Construction
'_'.❑I am a sole proprietor or partnership and have no employees working forme in $,.e-Remodeling
any capacity.[No workers'comp,insurance required]
9. El Demolition
3.&am a homeowner doing all work myself..[.No workers'comp,insurance required.]'
10 0 Building addition
4.[:]1 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 11.0 Electrical repairs or additions
proprietors with no employees.
12.Q Plumbing repairs or additions
50 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.QRoof repairs
These sub-contractors have employees and have workers`comp.insurance.,
6.[—]we are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Otber
152,§1(4),and we have no employees.[No workers'comp,insurance required.]
*Any applicant that cheeks 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 time of the sub-contractors and state whether or not those entities have
employees. if the sub-contractors have employees.they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job 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 MGL c.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 may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereby certify under thepains enalties o perjury that the information provided above is true and correct
S i arnature: Date:
Phone#: "tfi
Official use only. Do not write in this area,to be completed bl•circ'or rown 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#: