Workers Comp Affidavit & CertificateThe Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 021144017
kvi www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNHTTING AUTHORITY.
Name
City/State/Zip: N�P�ila'�PY-flNt MA'
Are you an employer? Check the appropriate box:
Phone #: L�Lt,) -L(701
1.❑ I am a employer with employees (full and/or part-time).•
2.F1 I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.Fj I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
S.D(I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.t
6. F1 We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no employees. [No workers' comp. insurance required.]
Type ofpraject(required):
7. ❑ New construction
8. Remodeling
9. ❑ Demolition
10 ❑ Building addition
11.❑ Electrical repairs or additions
12. ❑ Plumbing repairs or additions
13. ]Roof repairs
14.
:]Other
Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infomration.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mus[ submit a new affidavit indicating such.
(Contractors that check this box must attached an additional sheet showing the name of the 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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. A^,
Insurance Company Name: k4 AA '• l Ut'%A'L/ I N 5; o C
� Off• J
Policy # or Self -ins. Lic. #: / �'1 C C � �0 0 - Deb 6 5 3 � ' a &: xo nation Date: /j'/ y
Job Site Address: (gCNAA G l CA=P6 City/State/Zip:_NOAxi%rrA�/UPjDN, Mr
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).0 fn60
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. 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 pains an ad penalties of erjury that the information provided above is true and correct.
Signature: _ Date: J l d /Jo
Phone #:X113-21
%
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 #:
WRIGBUI-01 KA)
CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY)
E/3/2020
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the
certificate
holder is an ADDITIONAL INSURED, the policy(ias, must have ADDITIONAL INSURED provisions
or 6e endorsed.
If SUBROGATION IS
WAIVED,
subject to
the terms and conditions of the policy, certain policies may require an endorsement.
A statement on
this certificate does net
confer rights to the
certificate holder in lieu of such endorsements).
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE n OCCUR
PRODUCER � NAME�� nays rararrc L/r rr ri
3hill!
Insurance Agency, INC. PHONE 413 594-5984
)7 Center Street (AIC, No, Exll: ( )
.htconee. MA 01013 a u .l .. kayla@phillipsin:
INSURED
Wright Builders, Inc.
48 Bates Street
Northampton, MA 01060
(:hVFRA(:FS
r:FRTIFICATF NIIMRFR�
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTRINSO
TYPE OF INSURANCE
ADDL
SUBR
MD
POLICY NUMBER
POLICY EFF
M DD(MMIDDIYYYYI
POLICY
EXP
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE n OCCUR
TBD
3/1/2020
3/1/2021
EACH OCCURRENCE
$ 190002000
DAMAGET TO
E D
PREMMED
100'000
EXP Ano
$ 51000
PERSONAL&ADV INJURY
120009000
GEN'L AGGREGATE LIMIT APPLIES PER:
X POLICY FX] PES LOC
OTHER:
GENERAL AGGREGATE
230007000
PRODUCTS-COMP/OP AGG
$ 21000'000
EE Benefits
1,000,000
AOMBBINEDISINGLE
AUTOMOBILE LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY X AUTOS
X V./ p
XAUT030NLY AUTOS ONfY
TBD
3/112020
31112021
LIMIT
(Ea accen
1,0003000
BODILY INJURY Perperson)
$
BODILY INJURY Per accident)
PROPERTY AMAGE
Per accrdent
A
X
UMBRELLA UAB
EXCESS LIAB
X
OCCUR
CLAIMS -MADE
TBD
311/2020
3/112021
EACH OCCURRENCE
$ 510003000
AGGREGATE
530003000
DED
I X
I RETENTION$ 10,000
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORIPARTNER/EXECUTIVE
EXCLUDED'! N
,Mandatory in NH)
Ryes, describe under
DESCRIPTION OF OPERATIONS below
NIA
MCC -200-20005344020A
3/1/2020
311/2021
XSTATUTE
ERN
E.L. EACH ACCIDENT
NTFICER/MEMBER
500,000
E.L. DISEASE - EA EMPLOYEE
$ 500'000
E.L. DISEASE - POLICY LIMIT
1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
SHOULD ANY OF THE ABOVE bESCRIBED POLICIES BE CANCELLED BEFORE
Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED
yREPRESENTATIVE
I
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