Fillable Commonwealth of Massachusetts Department of Industrial Accidents Form-153 Affidavit of Exemption

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Commonwealth of Massachusetts Department of Industrial Accidents Form-153 Affidavit of Exemption

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The Commonwealth of Massachusetts Department of Industrial Accidents Form-153 Affidavit of Exemption form is 1 page long and contains:

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  • 11 other fields

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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations - Dept. 153
Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111-1750
www.mass.gov/dia
AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORATE
OFFICERS OR DIRECTORS
Chapter 169 of the Acts of 2002 amended M.G.L. c. 152, §1(4) by adding the following paragraph:
“This chapter shall be elective for an officer or director of a corporation who owns at least 25 percent of
the issued and outstanding stock of the corporation. Notwithstanding section 46, these provisions shall
apply only if the corporate officer provides the commissioner of industrial accidents with a written
waiver of his rights under this chapter. Said commissioner shall promulgate regulations to carry out the
purpose of this paragraph. Violations of this paragraph shall subject the corporation to the penalties set
forth in section 25C.”
Pursuant to M.G.L. c. 152, §1(4) as amended, I/We the undersigned officers of:
___________________________________________________________________________________,
(Name of Corporation and Address)
each holding at least 25% of the issued and outstanding stock in said corporation, do hereby invoke the
right to be exempt from the provisions of M.G.L. c. 152, §25A and therefore are not required to carry a
workers’ compensation policy covering the undersigned corporate officer(s) or director(s). I/We the
undersigned do also waive any and all rights to make claims for benefits as defined in M.G.L. c. 152 for
any injuries that may be sustained while in the employ of the above-named corporation.
Further, I/we the undersigned do understand that, should the above-named corporation hire or have in
its employ any employee(s) in addition to the undersigned corporate officer(s) or director(s), said
corporation is required to obtain workers’ compensation coverage for the employee(s) as prescribed by
M.G.L. c. 152, §25A.
I/We the undersigned have read and understand the statements and obligations as delineated above and
I/we have checked the appropriate box below my/our name(s) indicating my/our desire to be exempt or
not to be exempt from the provisions of M.G.L. c. 152.
Signed under the pains and penalties of perjury:
______________________________ ______________________________ ________________
Signature Print Name & Title Date (mm/dd/yyyy)
I wish to exercise my right of exemption or I wish NOT to exercise my right of exemption
______________________________ ______________________________ ________________
Signature Print Name & Title Date (mm/dd/yyyy)
I wish to exercise my right of exemption or I wish NOT to exercise my right of exemption
______________________________ ______________________________ ________________
Signature Print Name & Title Date (mm/dd/yyyy)
I wish to exercise my right of exemption or I wish NOT to exercise my right of exemption
______________________________ ______________________________ ________________
Signature Print Name & Title Date (mm/dd/yyyy)
I wish to exercise my right of exemption or I wish NOT to exercise my right of exemption
Note: ALL ELIGIBLE CORPORATE OFFICERS MUST SIGN. THERE CAN BE NO MORE THAN 4 SIGNATURES. Instructions
on back. Form 153 – 7/2019
FORM 153
DIA Use Only
Invest./SWO ID #: _____________
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PURPOSE & INSTRUCTIONS
Pursuant to M.G.L. c. 152, §1(4) workers’ compensation insurance “...shall be elective for an officer or director of
a corporation who owns at least 25% of the issued and outstanding stock of said corporation. Notwithstanding the
provisions of section 46 of this chapter, these provisions shall apply only if said corporate officer provides the
Commissioner of the Department of Industrial Accidents with a written waiver of his rights under this chapter.
The Commissioner of the Department of Industrial Accidents shall promulgate regulations to carry out the
purpose of this subsection. Violations of the terms of these provisions in any way shall subject said corporation to
the penalties set forth under section 25C of this chapter.”
Therefore in accordance with M.G.L. c. 152, §1(4) and 452 CMR c. 8.00 et. seq.:
• Such an exemption DOES NOT apply to employees of such a corporation who are not corporate
officers. Those employees must be covered by a valid workers’ compensation policy at all times.
• A copy of this form should be submitted to the insurance carrier on an annual basis, prior to the
renewal of any existing policy, as affirmation that the statements contained herein remain in effect. If
there has been ANY change in status of a corporate officer or director, a new Form 153 must be filed
with the DIA and provided to the insurance carrier.
• Any corporation in which the corporate officers or directors own at least 25% interest in the
corporation may exercise their right to exempt said corporate officers or directors from the provisions
of the Massachusetts Workers’ Compensation Act (M.G.L. c. 152).
• If the corporation named on this form employs no persons other than the eligible corporate officer(s)
or director(s) who have exercised their right of exemption by signing the Form 153, said corporation
may legally operate without workers’ compensation coverage. However, the corporation may not
employ any person other than those corporate officers or directors who have exercised their right of
exemption by signing the Form153. Should the corporation hire additional employees, workers’
compensation coverage must be obtained for those employees.
• The completed Form 153 must be submitted to the Department of Industrial Accidents, Office of
Investigations for the exemption under M.G.L. c. 152, §1(4) to be invoked.
• The policies and procedures surrounding the exemption of a corporate officer or director are
governed by 452 CMR 8.06 et. seq.
• If your corporation is submitting this form in response to a notice or Stop Work Order (SWO) from
the DIA Office of Investigations, please write the Investigation ID Number or Stop Work Order
Number on that correspondence on the space provided in upper right hand corner of the front of this
form.
Instructions -
All eligible corporate officers must sign the form and indicate their choice to be exempt or not to
be exempt from the provisions of M.G.L. c. 152 by checking the appropriate box located under
their name and signature. Complete all information on the front of the form and submit it to:
Department of Industrial Accidents
Office of Investigations - Dept. 153
Lafayette City Center
2 Avenue de Lafayette
Boston, MA 02111-1750
For additional information visit our web site at www.mass.gov/dia. See 452 CMR c. 8.00 et. seq.
Form 153 – 7/2019
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Commonwealth of Massachusetts Department of Industrial Accidents Form-153 Affidavit of Exemption

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Completed 22 May 2020

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