Massachusetts Workers' Compensation Poster Required

NOTICE TO 
EMPLOYEES  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: 	
  	
NAME OF INSURANCE COMPANY 	
 	
ADDRESS OF INSURANCE COMPANY 	
 
POLICY NUMBER   EFFECTIVE DATES  
 
NAME OF  INSURANCE  AGENT   ADDRESS  PHONE # 
 
EMPLOYER   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 ser- 
vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and 
reasonably connecte d 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