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Workers comp affidavit ma

Workers comp affidavit ma 2025

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The document is a Workers’ Compensation Insurance Affidavit from the Commonwealth of Massachusetts Department of Industrial Accidents, intended for builders, contractors, electricians, and plumbers. It requires applicants to provide information about their business, employee status, and insurance coverage in compliance with Massachusetts General Laws chapter 152. The affidavit must be completed accurately and submitted to the relevant city or town authority for permit or license applications. Failure to comply may result in penalties.

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Click ‘Get Form’ to open the workers comp affidavit ma in the editor.
Begin by filling in your name, address, city/state/zip, and phone number in the Applicant Information section. Ensure all details are printed legibly.
Indicate your employment status by checking the appropriate box: whether you are a general contractor, sole proprietor, homeowner, or corporation. If applicable, provide information about any subcontractors hired.
Specify the type of project you are undertaking by selecting one from the list provided. This is a required field.
If you are an employer providing workers' compensation insurance, fill in your insurance company name, policy number, and expiration date. Attach a copy of your policy declaration page.
Finally, certify that the information is true by signing and dating the affidavit before submitting it to the relevant city or town office.

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Versions	Form popularity	Fillable & printable
2019	4.9 Satisfied (59 Votes)
2013	4.8 Satisfied (486 Votes)
2007	4 Satisfied (57 Votes)
2006	4 Satisfied (33 Votes)

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