COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF INDUSTRIAL ACCIDENTS
OFFICE OF INSURANCE
I OBJECT TO CANCELLATION OF MY ASSIGNED RISK WORKERS’ COMPENSATION POLICY:
______________________ __________________ ___________________ ______________________
INSURER POLICY NO. COVERAGE PERIOD DATE OF CANCELLATION
_________________________________________ __________________________________________
NAME OF POLICYHOLDER POLICYHOLDER’S ADDRESS
_____________________ _________________ _________________ ________________________
EMAIL TELEPHONE CELLULAR FAX
________________________________________ _________________ ________________________
SIGNATURE OF PERSON FILING OBJECTION DATES: FILING + CANCELLATION RECEIVED
__________________________________________ ________________________________________
PRINTED NAME OF PERSON FILING OBJECTION POSITION WITH EMPLOYER
I REQUEST A HEARING UNDER GL C. 152, §65b FOR THE FOLLOWING REASONS:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
(USE OTHER SIDE OF PAPER IF NECESSARY)
TO OBTAIN A HEARING DATE, SEND DOCUMENTATION SUPPORTING YOUR OBJECTION TO:
OFFICE OF GENERAL COUNSEL, LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON MA
02111-1750. TEL: (857) 321-7356.
Chapter 152: § 65B. Cancellation or termination of policy; review
Section 65B. If, after the issuance of a policy under section sixty-five A, it shall appear that the employer to whom the
policy was issued is not or has ceased to be entitled to such insurance, the insurer may cancel or otherwise terminate
such policy in the manner provided in this chapter; provided, however, that any insurer desiring to cancel or otherwise
terminate such a policy shall give notice in writing to the rating organization and the insurer of its desire to cancel or
terminate the same. Such cancellation or terminations shall be effective unless the employer, within ten days after the
receipt of such notice, files with the department’s office of insurance objections thereof, and, if such objections are filed,
the commissioner, or his designee shall hear and decide the case within a reasonable time thereafter. Further appeal of
the decision of the department may be taken to the superior court for the county of Suffolk.
click to sign
signature
click to edit
![]()
