Massachusetts > Workers Comp
Insurer Request Certification - Massachusetts
| Insurer Request Certification 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 600 Washington Street, 7th Floor Boston, Massachusetts 02111 DEVAL L. PATRICK Governor TIMOTHY P. MURRAY Lieutenant Governor PAUL V. BUCKLEY Commissioner PROCESS FOR SUBMITTING INSURER REQUEST CERTIFICATION FORM 1. 2. Fill out Insurer Request Certification Form (attached) Return ONLY that form to Thomas Finneran at the address indicated on the bottom of the form We will send a letter to your office certifying that the employer is uninsured We will also send an Affidavit of Employee an Application for Trust Fund Benefits for the employee/claimant to fill out. Attach the Certification Letter and the completed Affidavit to the original claim and forward to: OFFICE OF CLAIMS ADMINISTRATION DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 WASHINGTON STREET, 7TH FLOOR BOSTON, MASSACHUSETTS, 02111 3. 4. 5. Tel. # (617) 727-4900 - www.mass.gov/dia American LegalNet, Inc. www.FormsWorkFlow.com INSURER REQUEST CERTIFICATION 1. I, ______________________________________________________, certify that the following attempts were made to (Employee Attorney) to obtain insurer information (Employer & Employer's Address) , an employee of that organization, Regarding the claim of (Employee) And that to the best of my knowledge no insurance coverage was in force for that company on ________________ (Date of Injury) 2. The following corporate officers/owners were contacted: NAME/TITLE PHONE DAY/DATE/TIME 3. ( ) I did approach the place of business. ( ) I did not approach the place of business. Why not: _______ 4. ( ) The employee requested the information from his/her employer. What was he/she told? By whom? _______ ( ) The employee did not request the information from his/her employer. Why not? All sections of this form must be completed. Any exclusions and/or deletions will be cause for return of the claim application and delay in processing. 5. Employee Attorney Attorney Address & Telephone Number Claimant This form requires BOTH signatures Return to: Department of Industrial Accidents Attn: Thomas Finneran th 600 Washington Street, 7 Floor Boston, MA 02111 Tel. # (617) 727-4900 - www.mass.gov/dia American LegalNet, Inc. www.FormsWorkFlow.com
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