Free Insurance Certification Request Form - Massachusetts

THE COMMONWEALTH OF MASSACHUSETTS Department of Industrial Accidents
600 Washington Street, 7th Floor Boston, Massachusetts 02111

DEVAL L. PATRICK Governor TIMOTHY P. MURRAY Lieutenant Governor

PAUL V. BUCKLEY Commissioner

Process for Submitting Insurer Request Certification Form 1. Fill out Insurer Request Certification Form. (Attached). 2. Return ONLY that form to Office of Insurance at the address indicated on the bottom of the form. 3. The office of Insurance will send a letter to your office certifying that the employer is uninsured. 4. The office of Insurance will also send an Affidavit of Employee in Application for Trust Fund Benefits for the employee/claimant to fill out. 5. Attach the Certification Letter and the completed Affidavit to the original Form 110 ­ Employee Claim form and forward to: Office of Claims Administration Department of Industrial Accidents 600 Washington St., 7th Fl. Boston, MA 02111

Tel. # (617) 727-4900 - www.mass.gov/dia

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: Michael W. Owen 600 Washington Street, 7th Floor Boston, MA 02111
Tel. # (617) 727-4900 - www.mass.gov/dia