Fillable Workers-compensation-affadavit - Online Workers Comp Affidavit

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Workers-compensation-affadavit - Online Workers Comp Affidavit

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U.S.A. forms for Town of Belmont

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TheCommonwealthofMassachusetts

DepartmentofIndustrialAccidents

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www.mass.gov/dia

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Workers’CompensationInsuranceAffidavit:Builders/Contractors/Electricians/Plumbers.



TOBEFILEDWITHTHEPERMITTINGAUTHORITY.





ApplicantInformation

Name

(Business/Organizational/Individual)

:________________________________________________________________________________________

Address:___________________________________________________________________City:_________________________________________

State:______________________________Zip:___________________Phone#:______________________________________________________

Areyouanemployer?Checktheappropriate box: Typeofproject(required):



1. Iamanemployerwithemployees(fulland/orparttime)*





7.Newconstruction

2. Iamasoleproprietororpartnershipandhavenoemployeesworkingformeinany

capacity.[Noworkers’comp.insurancerequired.]

8.Remodeling



9.Demolition



3. Iamahomeownerdoingallworkmyself.[Noworkers’comp.insurancerequired]†



10.Buildingaddition

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.

11.Electricalrepairsoradditions



12.Plumbingrepairsoradditions



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.±

13.RoofRepairs

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.]

14.Other

*Anyapplicantthatchecksbox#1mustalsofilloutthesectionbelowshowingtheirworkers’compensationpolicyinformation.

†Homeownerswh osubmit thisaﬃdavitindicangtheyaredoingallworkandthenhireoutsidecontractorsmustsubmitanewaffidavitindicatingsuch.

±Contractorsthatcheckthisboxmustattach

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:__________________________________________________________________________________________________________

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,andthatclicking

this

checkboxandtypingmynameinthefieldbelowwillactasmysignature.

Name:__________________________________________________Date:___________________________________________________________

Phone#:________________________________________________Email:__________________________________________________________





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Completed 11 July 2020

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