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Workers Comp affidavit(Signed)1 (3)Applicant Information Please Print Legibly Business/Organization Name:_________________________________________________________ Address:__________________________________________________________________________ City/State/Zip:_____________________________ Phone #:________________________________ *Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers’ compensation policy is required and such an organization should check box #1. I am an employer that is providing workers’ compensation insurance for my employees. Below is the policy information. Insurance Company Name:______________________________________________________________________________ Insurer’s Address:_____________________________________________________________________________________ City/State/Zip: ________________________________________________________________________________________ Policy # or Self-ins. Lic. # Expiration Date: 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, under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: 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. Licensing Board 5. Selectmen’s Office 6. Other _______________________________ Contact Person:_________________________________________ Phone #:_________________________________ 1. I am a employer with _________ employees (full and/ or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers’ comp. insurance required] 3. We are a corporation and its officers have exercised their right of exemption per c. 152, §1(4), and we have no employees. [No workers’ comp. insurance required]** 4. We are a non-profit organization, staffed by volunteers, with no employees. [No workers’ comp. insurance req.] Are you an employer? Check the appropriate box:Business Type (required): 5. Retail 6. Restaurant/Bar/Eating Establishment 7. Office and/or Sales (incl. real estate, auto, etc.) 8. Non-profit 9. Entertainment 10. Manufacturing 11. Health Care 12. Other _____________________________ www.mass.gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers’ Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Valley Solar LLC 340 Riverside Drive PO BOX 60627 Florence, MA 01062 413-584-8844 Liberty Mutual WC531S620647019 Solar Portsmouth, NH 03802 PO BOX 7202 2/1/2021 413-584-8844 11 08/18/2020