Massachusetts > Workers Comp

Insurance Inquiry Form - Massachusetts

Insurance Inquiry Form Form. This is a Massachusetts form and can be used in Workers Comp .
 Fillable pdf Last Modified 10/30/2013
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THE COMMONWEALTH OF MASSACHUSETTS Department of Industrial Accidents 19 Staniford Street, 5th Floor Boston, Massachusetts 02114 DEVAL L. PATRICK PHILIP L. HILLMAN OFFICE OF INSURANCE INSURANCE REGISTER (617) 626-5480 OR (617) 626-5481 INSURANCE INQUIRY FORM Governor TIMOTHY P. MURRAY Director Lieutenant Governor Use this version for mailed in or faxed (617-624-0985) submissions. Responses to faxed requests cannot be faxed back. Use the online version if your e-mail account does not have an attachment filter. (Revised 3/2013) Please fill out this form legibly, and remember to enter your mailing address at the bottom to receive our researched response. If the employer name is incorrect, insurance information may not be found. Take the employer name from a payroll, income tax or social security document issued during the calendar year within which the injury occurred. COMPANY NAME(S) ____________________________________________________ ADDRESS _________________________________________________________ __________________________________________________________________ WHAT IS ANOTHER NAME UNDER WHICH THE COMPANY COULD BE OPERATED? ___________________________________________________________________ DATE OR PERIOD OF INJURY _____________________________________________ HOW LONG HAS THE COMPANY BEEN IN BUSINESS? _____________________ WORKERS' COMPENSATION INSURANCE INFORMATION SHOULD BE REQUESTED FROM THE EMPLOYEE'S COMPANY FIRST. CALL AND ASK TO SPEAK WITH THE APPROPRIATE PERSON AT THE COMPANY WHO WOULD HAVE THE KNOWLEDGE OF THIS INFORMATION. IF INSURANCE INFORMATION CANNOT BE FOUND FOR THE EMPLOYER NAME SUBMITTED, SUCH A FINDING DOES NOT NECESSARILY MEAN THAT THE ENTITY WAS NOT OR IS NOT INSURED YOUR NAME AND ADDRESS (TO MAIL BACK THIS FORM TO YOU): _______________________________________________________ _______________________________________________________ _______________________________________________________ Tel. # (617) 727-4900 - www.mass.gov/dia American LegalNet, Inc. www.FormsWorkFlow.com
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