Commonwealth of Massachusetts Department of Industrial Accidents Notice to Employees

The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MA 02111
(617) 727-4900 – 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:

Insurer: The Commonwealth of Massachusetts Human Resources Division Workers' Compensation Unit
Address: 100 Cambridge Street, Suite 600, Boston, MA 02114
Policy number: N/A - self insured
Name of Insurance Agent: Massachusetts Human Resources Division Claims Unit
Address: 100 Cambridge Street, Suite 600, Boston, MA 02114

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: N/A