MA5106 WCThe Commonweulth of Massachusetts
Department of Industrial Accidents
Office of Investigutions
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lesiblv
Name (Business/Otganization/Individual) i
Address:PO Box 571
East Coast Communications
phone 9.207-839-3488
Are you an employer? Check the appropriate box:
f.E f amaemployerwith 38 4.E IamageneralcontractorandI
employees (full and/or part-time;.* have hired the sub-contractors
Z.Z tam a sole proprietor orpartner- 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'I
reouired.l 5. I We are a corporation and its
:. n f am a homeowner doing all work offtcers have exercised their
myself. [No workers' comp. right of exemption per MGL
insurance required.] t c.152, $l(4), and we have no
employees. [No workers'
Type of project (required):
6. ! New construction
7. f] Remodeling
8. I Demolition
9. E Building addition
10.I Electrical repairs or additions
I l.[ Plumbing repairs or additions
12.I Roof repairs
I 3. E Otherwireless telecommunications
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
lContractors that check this box must attached an additional sheet showing the name ofthe 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 um un employer that is providing workers' compensation insurunce for my employees. Below is the policy and job site
information.
Insurance Company Name:Maine Employers Mutual lnsurance Company
Policy # or Self-ins. Lic. #:5101800130 Expiration Darc.}1120t2014
Job Site Address: 1 15 & '123 Elm Street Cirylsrarclzrp North Hampton MA 01060
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section25A 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 andei
phone #: 207-839-3488
thst the information provided ubove is true und correct.
07 t2312013
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 #: