WC AffidavitThe 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/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):______________________________________________________
Address:__________________________________________________________________________
City/State/Zip:_____________________________ Phone #:________________________________
*Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information.†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, 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.
Insurance Company Name:____________________________________________________________________________
Policy # or Self-ins. Lic. #:__________________________________________ Expiration Date:____________________
Job Site Address: 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 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 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. Electrical Inspector 5. Plumbing Inspector
6.Other ______________________________
Contact Person:_________________________________________ Phone #:_________________________________
Type of project (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____________________
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. I am a homeowner doing all work myself. [No workers’ comp. insurance required.]
†
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.
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. 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.]
Are you an employer? Check the appropriate box:
3/14/24