Workers Comp AffidavitThe Commonwealth of Massachusetts
Department of Industrial Accidents
= Office of Investigations
d 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): S u n B u g Solar
Add ress:411A Highland Ave., Suite 312
City/state/Zip: Somerville, MA, 02144 Phone 4:617 500 3938
Are you an employer? Check the appropriate box:
1F./ I am a employer with 70
4. F-1 I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2f I am a sole proprietor or partner-
listed on the attached sheet. $
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5.
❑We
are a corporation and its
required.]
officers have exercised their
3 am a homeowner doing all work
right of exemption per MGL
LJI
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6.
New construction
7.
Remodeling
8.
Demolition
9.
Building addition
10
Electrical repairs or additions
11
Plumbing repairs or additions
12
Roof repairs
13ZOther Solar Installation
*Any applicant that checks 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 name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: New York Marine and General Insurance
Policy # or Self -ins. Lic. #: WC201900015422
Job Site
Expiration Date: 4/30/20
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 Section 25A 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.
I do hereby certify,.undfir the p y* and penalties of perjury that the information provided above is true and correct.
617 506 3938
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 #: