Massachusetts Workers' Compensation Poster Mandatory

NOTICE TO EMPLOYEES
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF INDUSTRIAL ACCIDENTS

IF YOU ARE INJURED ON THE JOB:
• Immediately notify your employer that you have been injured.
Employer HR/Workers’ Compensation Contact

Phone Number

• Tell the medical provider that you have been injured at work and give the information below:
Insurance Carrier

Address

Employer

Address

Phone Number

• If the employer fails to report the injury to the insurer, the employee may file an Employee’s
Claim (Form 110).
• Additional information regarding your rights and eligibility for benefits pursuant the Workers’
Compensation law may be obtained by contacting the Department of Industrial Accidents at
617.727.4900 or visiting www.mass.gov/dia.

IF MEDICAL TREATMENT IS NEEDED:

Injured workers may select their own medical provider. Medical treatment costs that are
reasonable, necessary, and related to the work injury will be paid by the above-named
insurer.
If medical facility information is provided below, the above-named insurer
has a preferred provider arrangement and the insurer has arranged for your
initial treatment at:
Medical Facility:

Address:

_________________________________ _________________________________________________
Phone Number:
_____________________________

EMPLOYER: THIS NOTICE MUST BE FILLED OUT AND POSTED WHERE EMPLOYEES CAN READ IT PURSUANT M.G.L. C. 152, SECTIONS 21, 22, 30,
AND 75B (2). EMPLOYERS MAY NOT RETALIATE, DISCRIMINATE (IN ACCORDANCE WITH ANY APPLICABLE STATE OR FEDERAL LAWS WHICH
INCLUDES IMMIGRATION STATUS), OR PROVIDE FALSE INFORMATION ABOUT THE WORKERS’ COMPENSATION PROCESS TO THEIR
EMPLOYEES. THIS NOTICE MUST BE UPDATED, POSTED AND REDISTRIBUTED WHEN THERE ARE CHANGES TO THE INFORMATION.

REVISED JUNE 2024