Workers Comp - Bath HouseT he C o mmo nwe altlt of M ass ach us etts
Departme nt of I nd ustr ial A cc idents
OfJice of I nvestigatio ns
Lrtfoyette City Center
2 Avenue de Lafayette, Boston, MA 02III-1750
www.mass.gov/diu
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers
icant Informa
Name (Business/Organization/lnciiviclual): J.J.S. UNIVERSAL CONSTRUCTION COMPANY
Address: 63 ATRPORT ROAD
Citv/State/Zin: DUDLEY, MA 0'1571 phone #: 860-753-0452
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Are you an employer? Check thc appropriate box:
r E f amaernployerwith_5 _ 4 ! Iamageneral contlactorandl
employees (full and/or parl-tinre).* have hired the sub-contractors
Z I f atrr a sole proprietor or par.1ner- listed on the attached sheet.
ship and have no ernployees
working for rnc in any capacity.
[No workers' cortrp. insurance
requ ired.l
;.I f am a homeowner doing all work
nryse lf. l.No workers' comp.
insurance required..l t
l'hese sub-contractors have
employees and have workers'
contp. insurance.l
5. f We are a corporation and its
offlcers have exercised tlreir
right of exernption per MGL
c.152. \l(4), and we have no
employees. [No workers'
corrrp. insurancc requiled.l
Type of project (required):
6. ! New construction
7. I Rernodeling
8. ! Demolition
o I Building addiriorr
10.! F.lectrical repairs or additions
I l.! Plumbing repairs or additions
t2.ffi Root repairs
r:.8 otnerRQlotn.'KQ -.*- ,t^) trl
*A|l\appIicantthatchecksbclx#lntusta|strflltlutthescctionbelorr'shorving.theirrr,clrkers.ctlnlpensation
elltlllorecs. ll'the stttr-contraotols havg crttplovees. ths\'rnust providc their rrrlrkcrs contp. ltolicr nrrrrrbcl.
I am un entployer that is providittg workers'compensation insurunce./or nt1, entployees. Below is the polic.y und joh site
infbrnmtiort.
Insurance Cornpany Name: O'Connor & Company Insurance Agency Inc
Po I i cv ri "fh?'ffi [ tH' WS'3: he+ HJo.,4,pi rar i on D v:c 1 04 t ?4 t 202 1
.
robsireAddrcss: 85 KeSerV-air R12q1d,'',Ftu,. rilgled5=.NA O loS 3
Attach a copy of the workers' compensation policy dcclaration page (showing thc policy numbcr and expiration date).
Failure to secure coveragc as rcquired under Section 25A of MCl. c. 152 can Iead to thc irrposition of crirninal penalties ol'a
ttne up to $1,500.00 and/or one-year imprisonrrent, as well as civil penalties in the lbrnr of a SI'OP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statenrent may be forwarded to the Offlce of
I'-r".trlg"tt"rt .
I do hereby c tlte
Of/icial use only. Do ttot write in this area, to be conrpleted b.r' citv- or town tfficiat.
City or Town: Permit/l_,icense *
Issuing Authoritv (check one):
r n g;aro or uealttr zfl auiiaing Department :.lcitylTo*n Clerk 4.n Etectricat Inspector Slletumning
Inspector O.flOtner
Contact Person:Phone #: