Insurance Inquiry Form

INSURANCE INQUIRY FORM. This form from the Commonwealth of Massachusetts Department of Industrial Accidents (DIA) is used to request information about a company's workers' compensation insurance coverage. This form is typically submitted when an individual—often an injured employee—needs to confirm whether their employer had an active workers' compensation policy during the time of a workplace injury. To complete the form, the requester provides the employer's name and address, any alternate business names the company may operate under, the date or time period of the injury, and how long the company has been in business. The form also advises the requester to first contact the employer directly for insurance information, as failure to locate coverage through the DIA does not automatically mean the employer was uninsured. The completed form is mailed or emailed to the DIA’s Office of Insurance for processing. www.FormsWorkflow.com