FORM 154
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations - Dept. 154
Lafayette City Center, 2 Avenue de Lafayette, Boston, MA
02111-1750
VERIFICATION OF MASSACHUSETTS WORKERS’
COMPENSATION COVERAGE FOR OUT OF STATE
EMPLOYERS OPERATING IN MASSACHUSETTS
DIA Use Only
Massachusetts law mandates that all employers must provide workers’ compensation insurance
coverage for their employees. Out of state employers are required to provide Massachusetts
workers’ compensation coverage for all their employees working in Massachusetts. Employers
whose existing workers’ compensation insurance policies specifically list Massachusetts in section
3A of said policy’s information page, satisfy this requirement.
Please note that employers whose workers’ compensation insurance policies specifically list
Massachusetts in section 3C regarding all states coverage (with or without certain state
exclusions) shall provide verification from their insurance carrier that coverage is provided in
Massachusetts. To satisfy this requirement, the insurance carrier must complete this form
verifying that the employer meets all the mandatory requirements for indemnity workers’
compensation insurance coverage for all employees engaged in the employer’s Massachusetts
operations. Upon request, this form, a copy of the policy’s information page and a copy of any
policy clause or clauses, which set forth conditions under which section 3C will become effective,
must be submitted to the Office of Investigations of the Department of Industrial Accidents.
PLEASE NOTE THAT THIS FORM MUST BE COMPLETED BY THE INSURANCE
CARRIER PROVIDING COVERAGE TO THE EMPLOYER.
INSURED’S INFORMATION
1. Legal Name and Address of the Insured (P.O. Box Not Acceptable):
2. All Massachusetts Work Locations of Insured:
3. Business Telephone Number of Insured:
4. Federal Employer ID Number or Social Security Number of Insured:
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