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| Insurance Quarterly Assessment Payment |
| Private Trust Assessment / Special Trust Assessment |
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It is mandatory that each assessed entity submit two separate payments: One payment for the Private Trust and one payment for the Special Trust. You will first make a payment to the Private Trust fund. After completing and submitting this transaction, you will be directed to enter the Special Trust Assessment payment. |
| I hereby certify under the pains and penalties of perjury that all laws of the Commonwealth governing assessments and regulations thereof have been complied with and observed, and that all payment information to be entered is, to the best of my knowledge, correct. | ||||
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The DIA does not accept aggregated reporting information. Information is mandatory for each company licensed to write workers compensation insurance in the Commonwealth of Massachusetts. Incomplete forms will be considered to be delinquent and subject to a 5% fine. |
| Please visit www.mass.gov/dia |
| THE COMMONWEALTH of MASSACHUSETTS DIA TAX ID IS: 046002284 |