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MASSACHUSETTS WORKERS COMPENSATION ASSIGNED RISK POOL APPLICATION FOR WORKERS COMPENSATION INSURANCE The Workers Compensation Rating & Inspection Bureau of Massachusetts 101 Arch Street, 5th Floor,
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01
Begin by entering the worker's name and contact information in the designated fields.
02
Provide the worker's job title and a description of their duties.
03
Indicate the worker's wage or salary rate and the number of hours worked per week.
04
Specify the dates of employment for the worker.
05
Enter any relevant injury or illness details, including the nature of the incident, the body parts affected, and the extent of the injury.
06
Provide information on any medical treatment received by the worker, including the names of doctors and hospitals involved.
07
Describe any disability or impairment resulting from the injury or illness.
08
Include any wages paid or payable to the worker during their disability period.
09
Sign and date the form to certify its accuracy and completeness.

Who needs form workers compensation rating?

01
Employers who have employees and are required to have workers' compensation insurance need to fill out form workers compensation rating. This form is used to provide information about the rating classification and payroll of each employee for insurance purposes.
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Form workers compensation rating is a document used to determine the appropriate workers' compensation insurance premium rates for employers based on their classification and claims history.
Employers who are subject to workers' compensation insurance laws and have employees are required to file the form.
To fill out the form, employers must provide accurate information regarding their business operations, including payroll, employee classification codes, and any past workers' compensation claims.
The purpose of the form is to ensure that employers pay the correct amount for workers' compensation insurance premiums, reflective of their risk and claims history.
Information that must be reported includes the number of employees, payroll amounts, employee job classifications, and historical claims data.
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