Fillable MA Department of Industrial Accidents - Insurer Request Certification Form

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MA Department of Industrial Accidents - Insurer Request Certification Form

On average this form takes 9 minutes to complete

The MA Department of Industrial Accidents - Insurer Request Certification Form form is 2 pages long and contains:

  • 2 signatures
  • 4 check-boxes
  • 25 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Tel. # (617) 727-4900 - www.mass.gov/dia
PROCESS FOR SUBMITTING
INSURER REQUEST CERTIFICATION FORM
Use this version for a mailed in or faxed ((617) 624-0985)
submission. Responses to faxed requests cannot be faxed back. Use
the online version if your e-mail account does not have an
attachment filter. Also be advised that any returned online version in
need of adjustment requires that a new online form be completely
filled out and submitted with the requested adjustment incorporated
into it.
1. Print and then fill out the Insurer Request Certification Form that
follows.
2. Forward that form to Thomas Finneran at the address indicated at
the bottom of the form, or fax it to his attention.
3. If the form has been completed correctly and no coverage is
found for the submitted employer name, then a letter will be sent
to the submitter’s office certifying that name as uninsured, along
with an Affidavit of Employee In Application For Trust Fund
Benefits document for the employee/claimant to fill out.
4. Attach the Certification Letter, the completed Affidavit (Form
170) and the original (or a completed) Employee Claim (Form
110) and forward to:
OFFICE OF CLAIMS ADMINISTRATION
DEPARTMENT OF INDUSTRIAL ACCIDENTS
LAFAYETTE CITY CENTER
2 AVENUE de LAFAYETTE
BOSTON, MA 02111-1750
THE COMMONWEALTH OF MASSACHUSETTS
Department of Industrial Accidents
Office of Insurance
19 Staniford Street, 5
th
Floor
Boston, Massachusetts 02114
ROSALIN ACOSTA
Secretary
SHERI BOWLES, J.D.
Interim Director
CHARLES D. BAKER
Governor
KARYN E. POLITO
Lieutenant Governor
INSURER REQUEST CERTIFICATION
1.
I, _________________________________, certify that the following attempts were made to
(Employee Attorney)
___________________________________________________to obtain insurer information
(Employer & Employer’s Address)
regarding the claim of _____________________________, an employee of that organization,
(
Employee)
and that to the best of my knowledge no insurance coverage was in force for that company on
__________________________________________.
(
Date of Injury)
2.
The following corporate officers/owners were contacted:
NAME/TITLE PHONE DAY/DATE/TIME
_______________________ _______________________ _________________________
_______________________ _______________________ _________________________
_______________________ _______________________ _________________________
_______________________ _______________________ _________________________
3.
( ) I did approach the place of business.
( ) I did not approach the place of business. Why not? _______________________________
__________________________________________________________________________
__________________________________________________________________________
4.
( ) The employee requested the information from his/her employer.
What was he/she told? ________________________________________________________
By whom? _________________________________________________________________
___________________________________________________________________________
( ) The employee did not request the information from his/her employer.
Why not? __________________________________________________________________
All sections of this form must be completed. Any exclusions and/or deletions will be
cause for return of the claim application and delay in processing.
5.
____________________________________
Employee Attorney
___________________________________________________________________________
Attorney Address & Telephone Number
___________________________________________________________________________
Claimant
This form requires BOTH signatures
Return to: Department of Industrial Accidents
ATTN: Thomas Finneran
19 Staniford St., 5
th
Floor
Boston, MA 02114
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MA Department of Industrial Accidents - Insurer Request Certification Form

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Completed 17 May 2020

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