Workers Comp - Concession StandThe Commonwealth of Massacltusetts
Department of Industrisl Accidents
Office of Investigations
Lc{oyette City Center
2 Avenue de Lcrfayette, Boston, MA 02111-1750
www.mass.gov/dia
Workerst Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Lesiblv
Name (Business/Orsanization/lndividual): J.J.S. UNIVERSAL CONSTRUCTION COMPANY
Address: 63 AIRPORT ROAD
City/State/Zip: DUDLEY' MA 01571 phone #: 860-753-0452
Are you an employer? Check the appropriate box:
l.E larlaernploycrwitlr _ 5 l. I larnageneral contractorand I
ernployees (full and/or pa't-time).* have hired the sub-contractors
z. X I am a sole proprieror or panner-
ship and have no employees
working for rne in any capacity.
[No workers' cornp. insurancc
required.l
;.I I arn a horrreowner doing all work
myself. lNo workers' cornp.
insurance required.] -i
listed on the attached sheet.
These sub-contractors have
ernployees and have workers'
cornp. irrsurance.i
5. f We are a corporation and its
ofllcers have exercised their
right o1'excrnption per MGI-
c. I 52. \ l(4). and we have no
employecs. INo workers'
comp. insurance required.l
Type of project (required):
6. f New construrction
7. I Rernodeling
8. [] Demolition
9. n Building addition
10.! Irlectrical repairs or aclditions
I l.! Plumbing repairs or additions
l2.p Rool'Rairs _ (^l2.Xl Rool'rcoairs /1i;frurn.fig-RclV& lo 1'f's
*Any'applicantthatchccksbtlx#lnrrtsta|solj||outt|]cSectiollbc|olvshorvinr:tlreiru,tlrkcrs.c0I)rpc|lsatiOl1
entplo\ccs. ll'thesub-contracktrshavcerttployecs.thclrnustproviclcthcir$orkcrs'conrp.p()licrnunrtrcr.
I am un emplo.yer that is provitlirtg workers' compensution insurunce./itr m|, entplo.yees. Betow is tlrc policy aud job site
infttrmatiott.
Insurance Corrpany Name: O'Connor & Company Insurance Agency Inc.
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rob sirc,\,),),r,r, Q1O N. M arZ I g S*fe e: tIi,., srare zipflOfe nCe_, MA
Attach a copy of the workcrsn compensation policy dcclaration pagc (showing thc policy number and expiration out.p 16Z
Failure to secure coverage as required under Section 25A of MGI- c. 152 can Iead to the imposition of criminal penalties of a
firre up to $1.500.00 and/or one-year irnprisonrnent. as well as civil penalties in the fbrm of a STOP WORK ORDIIR and a flne
of up to $250.00 a day against the violator. tle advised that a copy of this staternent may be forwarded to the Office of
I"".rrtg"ti",,. .
theI do hereby cegli,
Official use onl!-. Do not write in lhis orea, to be contpleted bt ci6t or town officiat.
lssuinq Authority (check one):
I n noaro or lleatttr zn nuitoing Department :.flcityttown Cterk 4.n Etectricat tnspector S.fhlumbing
Inspector 6.f]Ottrer _
Contact Person:Phone ll: