Notice To Employees (Of Workers Compensation Coverage)
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Notice To Employees (Of Workers Compensation Coverage) Form. This is a Massachusetts form and can be use in Workers Comp.
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Tags: Notice To Employees (Of Workers Compensation Coverage), Massachusetts Workers Comp,
NOTICE
TO
EMPLOYEES
NOTICE
TO
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 - http://www.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice
that I (we) have provided for payment to our injured employees under the above-mentioned chapter by
insuring with:
NAME OF INSURANCE COMPANY
ADDRESS OF INSURANCE COMPANY
POLICY NUMBER
EFFECTIVE DATES
NAME OF INSURANCE AGENT
ADDRESS
EMPLOYER
PHONE #
ADDRESS
EMPLOYER’S WORKERS’ COMPENSATION OFFICER (IF ANY)
DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers’ Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL
ADDRESS
TO BE POSTED BY EMPLOYER
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