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, 2471(4) by adding the following paragraph: 223This 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.224 Pursuant to M.G.L. c. 152, 2471(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, 24725A and therefore are not required to carry a workers222 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 workers222 compensation coverage for the employee(s) as prescribed by M.G.L. c. 152, 24725A. 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 153 226 7/2019 FORM 153 DIA Use Only Invest./SWO ID #: American LegalNet, Inc. www.FormsWorkFlow.com PURPOSE & INSTRUCTIONS Pursuant to M.G.L. c. 152, 2471(4) workers222 compensation insurance 223...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.224 Therefore in accordance with M.G.L. c. 152, 2471(4) and 452 CMR c. 8.00 et. seq.: 225 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 workers222 compensation policy at all times. 225 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. 225 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 Workers222 Compensation Act (M.G.L. c. 152). 225 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 workers222 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, workers222 compensation coverage must be obtained for those employees. 225 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, 2471(4) to be invoked. 225 The policies and procedures surrounding the exemption of a corporate officer or director are governed by 452 CMR 8.06 et. seq. 225 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 153 226 7/2019 American LegalNet, Inc. www.FormsWorkFlow.com