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 t o 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 t 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 compl eted) Employee Claim (Form 110) and forward to: OFFICE OF CLAIMS ADMINISTRATION DEPARTMENT OF INDUSTRIAL ACCIDENTS LAFAYETTE CITY CENTER 2 AVENUE de LAFAYETTE BOSTON, MA 021 1 1 - 1750 THE COMMONWE ALTH OF MASSACHUSETTS Department of Industrial Accidents Office of Insurance 1 9 Staniford S treet , 5 th Floor Boston, Massachusetts 0211 4 ROSALIN ACOSTA Secretary SHERI BOWLES, J.D. Interim Director CHARLES D . BAKER Governor KARYN E. POLITO Lieutenant Governor American LegalNet, Inc. www.FormsWorkFlow.com INSURER REQUEST CERTIFICATION 1. I, , certify that the following attempts were made to (Employee Attorney) to obtain insurer information (Employer & Employer222s 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., 5th Floor Boston, MA 02114 American LegalNet, Inc. www.FormsWorkFlow.com