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Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia amjeugis pue atarm Iaunnp ajuG :64aadold moge aql jo Iaumo atp se jntuad Sujplmq a Ioj Aldde Agazaq I`o3pou anogv aqj 3uTpueisgpTAuOM :HQ .ON uocjelisi�ald SIHtuerl IoioeljuoD *C1 L- z I '),-?- :.I1TT.M0�Tll jO imgu mil se I!Tujod WTTiplTrq E IOj Aldde fga3aq I :,Qnflad jo soijleuad aqj wpun poOtS •NIOI.LVwuoaNII 3uoW 2Ioa aOVd.LXHNi HHS•.LIMHd ONaG'Ilflg HH.L HHQNifl G3WH0383d 3I80M'I,IV 803 SH.LI'IIgISN 0dSaH 3H.L 3NIf1SSV OS'IV SHHNiMO HYIS•VZtii.jaldegj•'I.O•IAI HHQNIII QNIf13 A.LNIVHVf10 HO LIIVHOOHd AIOLLd2I.LIaaV HH,L OZ SS333V aAVH.CONI OG QNIV H03 H'I$IOI'IH ,LONI 38V XWOM.LK3W3A0HdM HWOH H'IUVJI'IddV HOA SHO.LJVHINIOJHaS 80 SH013VIUM03 QaHH.LSI` 3,Hm 1 H.LIM S.LivIU IOD O.LNII ONIIHa.LNiH 80.LIWHHd NiMO HIHH.L ONIINIIV180 SHHNIMO :(Ajioads)Iaglo— P-"e,—�,o•I^mko toll 2UTppq :(uieldxo)jjuuzd umo Sujutejgo Iaunnp— 00.0001 1$IaPun qof :(u!eldxo)noel Aq papnloxa ilioM— :(s)uosem Sumollo3 aqj Ioj paambai jou sl uoilt'Asi2nd :legs Ap no, Aq)nTl I �,r b motleoilddd jnujad 3o oleQ :IVOM JO ssaaPPV c� ' �� .'�aJ Is /vl h i�a�icl Ia dddy paaa;gSa.r aq isnw Smua;ny;1377-to uoymodaoa n q;!m papv4uoo snq aaumoamoy aq;fl MOAT /� C •slojoe.Tluoo paja s, a.t Aq auop ag aauj3t r"L' f lC n �. ,..f c^ a^• ... 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