Request an exemption from workers’ compensation coverage

Some corporate officers or directors can request an exemption from workers’ compensation coverage. Find out if you are eligible, and how to make the request.

Office of Investigations Exemptions - Form 153

The Details

What you need

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

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
                 1 Congress St., Suite 100
                 Boston, MA 02114

  • 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
                  1 Congress St., Suite 100
                  Boston, MA 02114

Download and fill out Form 153 - Affidavit of Exemption for Certain Corporate Officers or Directors and fax to (617) 727-7749.

                 

Contact

Address

1 Congress Street, Suite 100, Boston, MA 02114

Fax

(617) 727-7749

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