COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF INDUSTRIAL ACCIDENTS OFFICE OF INSURANCE I OBJECT TO CANCELLATION OF MY ASSIGNED RISK WORKERS222 COMPENSATION POLICY: INSURER POLICY NO. COVERAGE PERIOD DATE OF CANCELLATION NAME OF POLICYHOLDER POLICYHOLDER222S ADDRESS EMAIL TELEPHONE CELLULAR FAX SIGNATURE OF PERSON FILING OBJECTION DATES: FILING + CANCELLATION RECEIVED PRINTED NAME OF PERSON FILING OBJECTION POSITION WITH EMPLOYER I REQUEST A HEARING UNDER GL C. 152, 24765b FOR THE FOLLOWING REASONS: (USE OTHER SIDE OF PAPER IF NECESSARY) TO OBTAIN A HEARING DATE, SEND DOCUMENTATION SUPPORTING YOUR OBJECTION TO: OFFICE OF GENERAL COUNSEL, 1 CONGRESS STREET, SUITE 100, BOSTON MA 02114. TEL: 617-727-4900, ext. 7356. Chapter 152: Section 65B. Cancellation or termination of policy; review Section 65B. If, after the issuance of a policy under section sixty-five A, it shall appear that the employer to whom the policy was issued is not or has ceased to be entitled to such insurance, the insurer may cancel or otherwise terminate such policy in the manner provided in this chapter; provided, however, that any insurer desiring to cancel or otherwise terminate such a policy shall give notice in writing to the rating organization and the insurer of its desire to cancel or terminate the same. Such cancellation or terminations shall be effective unless the employer, within ten days after the receipt of such notice, files with the department222s office of insurance objections thereof, and, if such objections are filed, the commissioner, or his designee shall hear and decide the case within a reasonable time thereafter. Further appeal of the decis ion of the department may be taken to the superior court for the county of Suffolk . American LegalNet, Inc. www.FormsWorkFlow.com