Massachusetts > Workers Comp
Notice To Employees (Of Workers Compensation Coverage) - Massachusetts
| Notice To Employees (Of Workers Compensation Coverage) Form. This is a Massachusetts form and can be used in Workers Comp . |
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NOTICE TO EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 - http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: NAME OF INSURANCE COMPANY ADDRESS OF INSURANCE COMPANY POLICY NUMBER NAME OF INSURANCE AGENT EMPLOYER ADDRESS ADDRESS DATE EFFECTIVE DATES PHONE # EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER American LegalNet, Inc. www.USCourtForms.com
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