IMG_1288The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumberse
TO BE FILED WITH THE PERMITTING AUTHORITY,
Name (Bus iness/OrganizatioNlndividual):
Address:
City/State/Zip/y.d�,o,
Are you an employer? Check the appropriate box:
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Phone #:('W3
I, [J I am a employer with employees (full and/or part-time).*
2.[3 1 am a sole proprietor or partnership and have no employees working forme in
any capacity. [No workers' comp. insurance required.]
3.2]1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4.01 am a homeowner and will he 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,
5.❑ 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 .+
6.0 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' cora ins
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Type of project (required):
7. El New construction
8. El Remodeling
9. El Demolition
10 Q Building addition
11.0 Electrical repairs or additions
12. []Plumbing repairs or additions
13.E]Roof repairs
14.�Other 1364� rod t/}�
P• urance requu•ed.] � ,
*Any applicant that checks box #1 must also 611 out the section below showing their workers' compensation Policy mfor o Ff 011ej 0.r �0. l
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 state whether or not those entities have
employees. If the sub -contractors have employees, thev must provide their workers' comp. policy number.
4,r! Uri enrproyer tnat is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address:
Attach a copy of the workers' City/State/Zip:
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 $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.
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t/KH{J ,.,,u peaacnes of perjury that the information provided above is true and correct.
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Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Contact Person:
Permit/License #
3. City/Town Clerk 4. Electrical Inspector
Phone #:
5. Plumbing Inspector
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