COMPThe Commonwealth of Massachusetts
Department of Industrial Accidents
- I Congress Street, Suite 100
a
Boston, MA 02II4-2017
www mass.gov/dia
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Business/Orgatuzation/Inditi-idual):
Address:
City/State/Zip: (A ti � � � � � 12 ru Phone #: —"//,3
Are you an employer? Check the appropriate bog:
1.Q I am a employer with employees (full and/orpart-time).*
2R, am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' cotup. insurance required_]
3.Fj 1 am a homeowner doing ail work myself. [No workers' comp. itzsurance regarired.j t
4.F I am a homeowner and will be hiring contractors to conduct all work on my property, 1 will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.[] 1 am a general contractor and 1 have hired the sub -contractors listed on the attached sheet.
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 M61_ c.
152, § 1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. ❑ New construction
S.Remodeling
9. El Demolition
10 ❑ Building addition
11. F-1 Electrical repairs or additions
I2. ❑ Plumbing repairs or additions
13 -[:]Roof repairs
14. ❑ Other
*Any applicant that checks box #1 must also fill our the section below showing their workers' compensation policy information.
' Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must subrnit a new affidavit indicating such.
tContractors that check ties box trust attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. Tf 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 and job site
information.
Insurance Company
Policy # or Self -ins. Lic. #: Expiration Date:
.lob Site Address: CitylState/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 S 1,500.00
and/or one-year imprisonment, as well as civil penalties in the forth 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.
I do hereby certify under the painsy#d penalties of perjury that the information provided above is true and correct
!�- ✓/ C Date:
Oficial use only. Do not write in this area, to be completed by city or town offrciaL
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 #: