Fillable Printable Workers' Compensation Form - Massachusetts

Workers' Compensation Form - Massachusetts

The Commonwealth of Massachusetts

Department of Industrial Accidents

Office of Investigations - Dept. 153

1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017

http://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, §1(4) by adding the following paragraph:

“This 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.”

Pursuant to M.G.L. c. 152, §1(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, §25A and therefore are not required to carry a

workers’ compensation policy covering the undersigned corporate officer(s) or director(s). I/We the

undersigned do also waive any and a ll rights to make claims for benefits as defined in M.G.L. c. 152 for

any injuries that ma y be sustained while in the e mploy 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 workers’ compensation coverage for the e mployee(s) as prescribed by

M.G.L. c. 152, §25A.

I/We the undersigned have read and understand the statement s 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. Instruction s

on back.

Form 153 – 7/2010

FORM 153

DIA Use Only

Invest./SWO ID #: _____________

PURPOSE & INSTRUCTIONS

Pursuant to M.G.L. c. 152, §1(4) workers’ compensation insurance “...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 righ ts under this chapter.

The Commissioner of the De partm e nt of Industrial Acci dents shall promulgate r e gulations 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 fo rth under sect ion 25C of this chapter.”

Therefore in accordance with M.G.L. c. 152, §1(4) and 452 CMR c. 8.00 et. seq.:

• Such an exemption DOES NOT apply to employees of such a corporation who are not corporate

officers. Those employees must be covered by a vali d workers’ compensation policy at all times.

• A copy of this form should be submitted to the insurance car rie r 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.

• Any corporation in which the corporate officers or directors own at least 25% interest in the

corporation may exercise t heir right to exempt said corporate officers or directors from the provisions

of the Massachusetts Workers’ Compensation Act (M.G.L. c. 152).

• 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 workers’ 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, workers’

compensation coverage must be obtained for those employees.

• 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, §1(4) to be invoked.

• The policies and procedures surrounding th e exemp tion of a corpo rate o fficer or dire c tor are

governed b y 452 CMR 8.06 et. seq.

• 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 correspondenc e 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

1 Congress Street, Suite 100

Boston, MA 02114-2017

For additional information visit our web site at <www.mass.gov/dia>. See 452 CMR c. 8.00 et . seq.

Form 153 – 7/2010