FORM 154 The Commonwealth of Massac h usetts Department of Industrial Ac ci dents Office of I n vestigatio n s - D ept. 154 Lafayette City Center, 2 Avenue de Lafayette, B oston, MA 02111 - 1750 VERIFI CA CO M PENSATION COVERAGE FOR OUT OF STATE E M PLOYERS OPERATING IN MASSACH U SETTS DIA Use Only Massac hu setts law mandates that all employers m u st p rovide w orker s com p ensati o n i n surance coverage for their e m ployees. Out o f st a te employers are required to provi d e Massac h use t ts w n sati o n coverage for all the i r employ ee s w orking in Massac h usetts. Employers w hose existing w compe ns ation in s urance pol i cies s pecifical l y list Mass a chusetts in section 3A of said p information page, satisfy this requirem e nt. P l ease note th a t employers w ho s e w compe n sation in s urance pol i cies s pecifica l ly list Massac hu setts in section 3C regarding all s t ates coverage (w i t h or w i thout certain state exclusions) shall provide ve r i fica t i on from their insurance ca r ri e r that cove r age is provided in Massac hu setts. To satisfy this requirement, the in s urance carrier must c o mplete this form verifying that the employer meets all t h e mand a t o ry requirements for indemnity w orker s compensation i n sura n ce cov e rage for all e mployees engaged in the Massachusetts operations. Upon req u est, this form, a copy of the information page a n d a copy of a n y policy clau s e or clause s , w hich set forth co n diti o n s u n der w hich section 3C w ill become effective, m u st be s u b mitted to t h e Office of Investigations of the Depa r tment of I ndu strial Accidents. P L EASE NOTE T HAT THIS F O RM MUST BE CO MP LETED BY THE INS U RANCE CARRIER PROVIDING COVERA G E TO T HE E M PL OYER. M ATION 1. Legal Name and Addre s s of the I n sured (P.O. Box Not Acceptable): 2. All Massac hu setts Work Locations of I n sured: 3. Business Telephone Number of I n sured: 4. Federal Employer ID N u m b er or Social Security Number of I n sured: - Ov er - American LegalNet, Inc. www.FormsWorkFlow.com M ATION 1. Name of I n surance Carr i er: 2. Name, Addre s s a n d Te l ephone Number of I ns urance Carr i er Contact Person: 3. Pol i cy Number of I n sured: 4. Pol i cy Term: 5. List the name of the Proprietor, or all Partners or all Officers of the I n s ured and check the a p propriate box belo w : All individuals listed above a r e inc l uded in the cov e rage p r ovided by the insurance carr i er. Some of the above listed individuals are e x cluded from t h e coverage provided b y the in s urance carr i er. These indivi du als are: This certifies that the i n surance carr i er listed above p rovides w compens a t ion in s urance cov e rage for its above - named i n s u in Ma s sach u set t s. The information contain e d herein is true to the best o f my k n o w l edge and belief. Signed under the pains and penalties of perjury. S igna t ure of In su rance Ca r ri e r R e presentative Print n a m e Date Title of Insurance Carrier Representative Direct Phone Line Email Address F or m 1 5 4 Am e nde d 7 / 2 01 9 American LegalNet, Inc. www.FormsWorkFlow.com