HomeMy Public PortalAboutworkers comp aff page 1The Commonwealth of Massachusetts
Department ofIndustrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mnss.gov/din
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 11:
Are you an employer? Check the appropriate box:
L❑ I am a employer with employees (full and/orpart-time).' 2.0 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.] 1
4. ❑ 1 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 subcontractors 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.]
Type of project (required):
7. 0 New construction
8. ❑ Remodeling
9. 0 Demolition
10 ❑ Building addition
11.0 Electrical repairs or additions
12. ❑ Plumbing repairs or additions
13. ❑ Roof repairs
14.0 Other
'Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
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 subcontractors 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 render the pains and penalties of perjury that the information provided above is true and correct.
Signature:
Phone #:
Date:
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 #: