Request a Certificate
ASSIGNED RISK/VDAC

Attention: For fast, 24-hour access, use the OAR online service.  OAR is the online Assigned Risk Services for Assigned Risk and VDAC - Massachusetts.  It's offered through the Workers' Compensation Rating & Inspection Bureau and allows you to verify coverage and request a certificate of insurance.  OAR Log-in
 
If you prefer to request a certificate directly from A.I.M. Mutual, please fill out the form below.
 
Please provide all of the requested information, including the facsimile number(s) of the person or persons to whom the Certificate of Insurance should be issued. If this form is fully and accurately completed, the Certificate of Insurance will be issued and distributed by facsimile to each fax number provided below, within two (2) business days of the carrier’s receipt. 
 
 
 
 
1. Name, address, telephone number and facilimile number or email address of the INSURED:
2. Name, address, telephone number and facilimile number or email address of the CERTIFICATE HOLDER:
3. Name, address, telephone number and facilimile number or email address of the PRODUCER:
4. Policy Number, Policy Effective Date and Policy Expiration Date

If a Certificate of Insurance is needed for more than one policy term, provide the Policy Number,
Effective Date and Expiration Date for each policy term.
If the policy has not yet been issued, you must attach a copy of the Notice of Assignment
5. List any special requests for optional coverages / endorsements (see below for listing of coverages available
in the pool and the conditions of availability) or additional information (including changes in exposure not yet
reported to A.I.M. Mutual) that will assist us in the issuance of the Certificate of Insurance.
NOTE: An additional insured(s) shall not be listed on any Certificate of Insurance unless such additional
insured(s) is a named insured on the policy.

 

 

 

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OPTIONAL COVERAGES / ENDORSEMENTS

 

NAME

ENDORSEMENT NO.

CONDITIONS OF AVAILABILITY

PREMIUM CHARGE

Alternate Employer

WC 00 03 01 A

Available if required by contract.

None

Defense Base Act

WC 00 01 01

Available upon request and if exposure exists.

 

Extension of USL & H. Same premium charge.

Designated Workplaces Exclusion

WC 00 03 02

Available upon request and if application is allowable under M.G.L. Ch. 152.

None

Domestic and Agricultural Workers Exclusion

WC 00 03 15

Available, but only to exclude part time domestic servants as defined by M.G.L. Ch. 152.

None

Federal Employers Liability Act - (Program I)

WC 00 01 04

Available. Used only in conjunction with State Act Coverage to provide employers liability protection under Program I for employments subject to FELA.

Refer to Part I of the MA Manual.

Longshore & Harbor Workers Act

WC 00 01 06 A

Available in conjunction with State Act Coverage, upon request and if exposure exists.

Non-F class rates are increased by USL&H compensation coverage % on MA Rates -Miscellaneous Values pages.

Maritime – (Program I)

WC 00 02 01 A

Available. Used only in conjunction with State Act Coverage to provide employers liability protection under Program I for admiralty law. *

Refer to Part I of the MA Manual.

If Transportation, Wage, Maintenance and Cure Coverage is required by contract, it can be provided at no fee by addition $0 in Item 2 of the Schedule.

Maritime – (Program II) Voluntary Compensation

WC 00 02 03

Available. To be used only with State Act Coverage and with WC 00 02 01 A to provide Program II coverage for admiralty law.

Refer to Part I of the MA Manual.

Massachusetts Benefits Deductible Endorsement

WC 20 06 02

Available. Insured must request the deductible program beforethe effective date of the policy, otherwise before the next renewal of the policy.

Apply the appropriate premium reduction percentage to the policy's standard premium. Refer to the Miscellaneous Values page of the MA Manual.

Massachusetts Benefits Claim and Aggregate Deductible Endorsement

WC 20 06 03

Available. Insured must request the deductible program beforethe effective date of the policy, otherwise before the next renewal of the policy.

Apply the appropriate premium reduction percentage to the policy's standard premium. Refer to the Miscellaneous Values page of the MA Manual.

Non-appropriated Fund Instrumentalities Act

WC 00 01 08 A

Available upon request and if exposure exists.

Extension of USL &H. Same premium charge.

Outer Continental Shelf Lands Act

WC 00 01 09 A

Available upon request and if exposure exists.

Extension of USL &H. Same premium charge.

Partners, Officers and Other Exclusion Endorsement

WC 00 03 08

Available. To be used to identify corporate officers or directors who own at least 25% of the issued and outstanding stock of a corporation and who have been approved to exclude themselves from coverage in accordance with M.G.L. Chapter 152, Section 1(4) and MA DIA Regulation 452 CMR 8.06.

None

Sole Proprietors, Partners, Officers and Others Coverage Endorsement

WC 00 03 10

Available. To be used to identify sole proprietors, partners, or members of an LLC who have elected to obtain coverage for themselves as employees in accordance with M.G.L. Chapter 152, Section 1(4) and MA DIA Regulation 452 CMR 8.07.

The premium basis for each sole proprietor, partner, or member of an LLC shall be based on a fixed amount equal to the State Average Weekly Wage x 52. Refer to the Miscellaneous Values page of the MA Manual for the fixed amount.

Voluntary Compensation and Employers Liability (FELA Program II)

WC 00 03 11 A

Available. To be used only in conjunction with State Act Coverage and with WC 00 01 04 to provide Program II coverage for employments subject to FELA.

Refer to Part I of the MA Manual.

 

Waiver of Our Right to Recover From Others

WC 00 03 13

Available if required by contract.

 

2% of developed premium for the specific job for which the endorsement is required.

 

* The Standard Limits of Liability are:

 

Bodily Injury or death - $ 5,000 - each employee Bodily injury or death - $ 10,000 - each accident

 

A maximum limit of $25,000/$25,000 is available.