Massachusetts > Workers Comp
Workers Compensation Insurance Affidavit - Building Plumbing Electrical Contractors - Massachusetts
| Workers Compensation Insurance Affidavit - Building Plumbing Electrical Contractors Form. This is a Massachusetts form and can be used in Workers Comp . |
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The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations th 600 Washington Street, 7 Floor Boston, Mass. 02111 Workers Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors Applicant information: Please PRINT legibly name: address: city state: zip: phone # work site location (full address): I am a homeowner performing all work myself. Project Type: New Construction Remodel I am a sole proprietor and have no one working in any capacity. Building Addition I am an employer providing workers compensation for my employees working on this job. company name: address: city: phone #: insurance co. policy # I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the following workers compensation polices: company name: address: city: phone #: insurance co. policy # company name: address: city: phone #: insurance co. policy # Attach additional sheet if necessary Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone # official use only do not write in this area to be completed by city or town official city or town: permit/license # Building Department Licensing Board check if immediate response is required Selectmens Office Health Department contact person: phone #; Other (revised Sept. 2003) <<<<<<<<<********>>>>>>>>>>>>> 2 Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers compensation for theiremployees. As quoted from the law, an employee is defined as every person in the service of another under anycontract of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more ofthe foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiveror trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of adwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house ofanother who employs persons to do maintenance, construction or repair work on such dwelling house or on the groundsor building appurtenant thereto shall not because of such employment be deemed to be an employer.MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance orrenewal of a license or permit to operate a business or to construct buildings in the commonwealth for anyapplicant who has not produced acceptable evidence of compliance with the insurance coverage required.Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for theperformance of public work until acceptable evidence of compliance with the insurance requirements of this chapter havebeen presented to the contracting authority. Applicants Please fill in the workers compensation affidavit completely, by checking the box that applies to your situation. Pleasesupply company name, address and phone numbers along with a certificate of insurance as all affidavits may besubmitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign anddate the affidavit. The affidavit should be returned to the city or town that the application for the permit or license isbeing requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or ifyou are required to obtain a workers compensation policy, please call the Department at the number listed below.City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom ofthe affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pleasebe sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned tothe Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,please do not hesitate to give us a call. The Departments address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations th 600 Washington Street,7 Floor Boston, Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406
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