Affidavit of Exemption for Corporate Officers
This file is an Affidavit of Exemption for Corporate Officers or Directors. It allows those owning at least 25% of a corporation's stock to exempt themselves from workers' compensation insurance requirements. It includes instructions and necessary signatures.
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How do I fill this out?
To fill out this form, provide the necessary corporate details and the contact information of the corporation. Ensure that all eligible corporate officers or directors who own at least 25% of the corporation sign the form. Check the appropriate box indicating the desire to be exempt or not exempt.
How to fill out the Affidavit of Exemption for Corporate Officers?
1
Provide the name and address of the corporation.
2
Enter contact details including name, phone, and email.
3
Corporate officers or directors owning at least 25% of the stock must sign.
4
Check the appropriate box to indicate the choice of exemption.
5
Submit the form to the Department of Industrial Accidents.
Who needs the Affidavit of Exemption for Corporate Officers?
1
Corporate officers owning at least 25% of the corporation need this file to exempt themselves from workers' compensation insurance.
2
Directors owning at least 25% of a corporation's stock require this form for exemption from workers’ compensation.
3
Corporations without additional employees other than exempt officers need this form to legally operate without workers' compensation.
4
Corporations responding to a Stop Work Order from the DIA need to complete this form as part of compliance.
5
Insurance carriers need a copy of this form for corporations renewing their policy annually.
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With PrintFriendly, you can easily edit this PDF file by entering the required corporate details and signatures. You can use our PDF editor to check the appropriate boxes and input contact information. Customize the form directly on our platform for your corporation’s specific needs.
1
Upload the PDF file to PrintFriendly.
2
Enter the corporation's details including name and address.
3
Add contact information such as phone and email.
4
Check the appropriate boxes for exemption.
5
Add digital signatures for all eligible corporate officers.
What are the instructions for submitting this form?
Submit the completed form to the Department of Industrial Accidents, Office of Investigations - Dept. 153, Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111-1750. You can also email it to DIAForm153@mass.gov. Ensure all fields are filled out correctly and all eligible corporate officers have signed.
What are the important dates for this form in 2024 and 2025?
The Affidavit of Exemption must be submitted annually before policy renewal. Specific dates may vary based on the corporation's insurance policy renewal date.
What is the purpose of this form?
The purpose of this form is to allow corporate officers or directors of a corporation who own at least 25% of the issued and outstanding stock to exempt themselves from the requirements of carrying workers' compensation insurance. This form must be properly filled out and signed by all eligible corporate officers. The exemption applies only to the officers or directors who sign the form and does not extend to other employees of the corporation.
Tell me about this form and its components and fields line-by-line.
- 1. Name of Corporation: The legal name of the corporation seeking exemption.
- 2. Address of Corporation: The physical address of the corporation.
- 3. Contact Name: The name of the person to contact regarding this form.
- 4. Phone: The phone number for contact purposes.
- 5. Email: The email address for contact purposes.
- 6. Signature: Signature of the corporate officer or director.
- 7. Print Name & Title: Printed name and title of the corporate officer or director.
- 8. Date (MM/DD/YYYY): The date the form is signed.
What happens if I fail to submit this form?
Failure to submit this form can lead to non-compliance with Massachusetts workers' compensation laws.
- Penalties: The corporation may face legal penalties for not complying with the requirement to carry workers' compensation insurance.
- Stop Work Orders: The Department of Industrial Accidents may issue a Stop Work Order against the corporation.
- Insurance Issues: The corporation may face difficulties in renewing its workers' compensation policy.
How do I know when to use this form?
- 1. Exemption Request: When officers or directors request an exemption from workers' compensation.
- 2. Policy Renewal: Prior to the annual renewal of a corporation's workers' compensation policy.
- 3. No Additional Employees: When a corporation has no employees other than the exempted officers or directors.
- 4. Stop Work Order Compliance: In response to a Stop Work Order from the Department of Industrial Accidents.
- 5. Change in Status: When there is a change in the status of an exempted corporate officer or director.
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Is this form legally compliant?
Yes, when properly filled out and signed, this form complies with Massachusetts law regarding exemption from workers' compensation.
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Can I use this form for multiple officers?
Yes, the form allows for up to four corporate officers or directors to sign.
Do I need to submit this form annually?
Yes, submit a copy of this form to your insurance carrier annually before policy renewal.
Where do I submit the completed form?
Send the completed form to the Department of Industrial Accidents at the specified address.
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