Contacts
Office of Investigations Exemptions - Form 153
The Details of Request an exemption from workers’ compensation coverage
What you need for Request an exemption from workers’ compensation coverage
Corporate officers who own at least 25% interest in the corporation can file a Form 153 - Affidavit for Certain Corporate Officers or Directors with the Department of Industrial Accidents (DIA) to request an exemption from workers compensation coverage.
- All eligible corporate officers must sign the Form 153, to exempt themselves
The exemption does not apply to employees who aren’t corporate officers.
How to request Request an exemption from workers’ compensation coverage
Download and fill out the Form 153 - Affidavit of Exemption for Certain Corporate Officers or Directors and mail it to:
Office of Investigations – Form 153
Department of Industrial Accidents
Lafayette City Center
2 Avenue de Lafayette
Boston, MA 02111-1750
- Companies in Massachusetts should use their Massachusetts address, not the address of the out-of-state corporate HQ
- If your company is submitting the form in response to a DIA notice of a stop work order, write the investigation ID number or stop work order number in the space provided on the upper right of the form
Download and fill out Form 153 - Affidavit of Exemption for Certain Corporate Officers or Directors and deliver to:
Department of Industrial Accidents
Lafayette City Center
2 Avenue de Lafayette
Boston, MA 02111-1750
Download and fill out Form 153 - Affidavit of Exemption for Certain Corporate Officers or Directors and fax to (617) 727-7749.
Download and fill out Form 153 - Affidavit of Exemption for Certain Corporate Officers or Directors and email it to: DIAForm153@mass.gov