The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers222 Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: City/State/Zip: Phone #: *Any applicant that checks box #1 must also fill out the section below showing their workers222 compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers222 compensation policy is required and such an organization should check box #1. I am an employer that is providing workers222 compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer222s Address: City/State/Zip: Policy # or Self-ins. Lic. # Expiration Date: Attach a copy of the workers222 compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under 247 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 (check one): Building Department 3. City/Town Clerk 4.1. Licensing Board Board of Health 2.5. Selectmen222s Office 6. Other Contact Person: Phone #: 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 workers222 comp. insurance required] 3. We are a corporation and its officers have exercised their right of exemption per c. 152, 2471(4), and we have no employees. [No workers222 comp. insurance required]** 4. We are a non-profit organization, staffed by volunteers, with no employees. [No workers222 comp. insurance req.] Are you an employer? Check the appropriate box: Business Type (required): 5. Retail 6. Restaurant/Bar/Eating Establishment 7. Office and/or Sales (incl. real estate, auto, etc.) 8. Non-profit 9. Entertainment 10. Manufacturing 11. Health Care 12. Other www.mass.gov/dia American LegalNet, Inc. www.FormsWorkFlow.com Information and Instructions City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department222s address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 Tel. (857) 321-7406 or 1-877-MASSAFE Fax (617) 727-7749 www.mass.gov/dia Form Revised 7/2019 Massachusetts General Laws chapter 152 requires all employers to provide workers222 compensation for their employees. Pursuant to this statute, an employee is defined as 223...every person in the service of another under any contract of hire, express or implied, oral or written.224 An employer is defined as 223an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.224 MGL chapter 152, 24725C(6) also states that 223every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required.224 Additionally, MGL chapter 152, 24725C(7) states 223Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority.224 Applicants Please fill out the workers222 compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company222s name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers222 compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers222 compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. American LegalNet, Inc. www.FormsWorkFlow.com