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 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