Affidavit For General Businesses Form - Department Of Industrial Accidents
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1
2The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Workers’ Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
Please Print Legibly
Business/Organization Name:_________________________________________________________
Address:__________________________________________________________________________
City/State/Zip:_____________________________ Phone #:________________________________
Business Type (required):
Are you an employer? Check the appropriate box:
5.
Retail
1.
I am a employer with _________ employees (full and/
or part-time).*
6.
Restaurant/Bar/Eating Establishment
2.
I am a sole proprietor or partnership and have no
7.
Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
8.
Non-profit
[No workers’ comp. insurance required]
9.
Entertainment
3.
We are a corporation and its officers have exercised
their right of exemption per c. 152, §1(4), and we have
10.
Manufacturing
no employees. [No workers’ comp. insurance required]**
11.
Health Care
4.
We are a non-profit organization, staffed by volunteers,
12.
Other _____________________________
with no employees. [No workers’ comp. insurance req.]
*Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers’ compensation policy is required and such an
organization should check box #1.
I am an employer that is providing workers’ compensation insurance for my employees. Below is the policy information.
Insurance Company Name:______________________________________________________________________________
Insurer’s Address:_____________________________________________________________________________________
City/State/Zip: ________________________________________________________________________________________
Policy # or Self-ins. Lic. #
Expiration Date:
Attach a copy of the workers’ compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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. Licensing Board 5. Selectmen’s Office
6. Other _______________________________
Contact Person:_________________________________________ Phone #:_________________________________
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