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Weight Loss Benefit Form (PDF)
Weight Loss Benefit Brochure (PDF)
Return to Wellness > Activities |
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Fitness Benefit Form (PDF)
Return to Wellness > Activities |
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Subscriber Submission Claim Form (PDF)
Return to Health Benefits Trust > Claims |
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Request for Outpatient Retail Pharmacy Prior Authorization (PDF)
This form must be completed and submitted by the prescribing physician only
Return to Health Benefits Trust > Claims |
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Student Certification Affidavit (PDF)
Return to Health Benefits Trust > Enrollment |
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Request for Retaining Coverage for a Psychologically or Physically Disabled Dependent Child (PDF)
Return to Health Benefits Trust > Enrollment |
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Medicare Part D - Sample Notice of Creditable Coverage - General (PDF) - 4/17/08
Return to Health Benefits Trust > Medicare Part D |
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Medicare Part D - Sample Notice of Creditable Coverage - General (MS Word file) - 4/17/08
Return to Health Benefits Trust > Medicare Part D |
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Medicare Part D - Sample Notice of Creditable Coverage - Detail (PDF file) - 4/17/08
Return to Health Benefits Trust > Medicare Part D |
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Medicare Part D - Sample Notice of Creditable Coverage - Detail (MS Word file) - 4/17/08
Return to Health Benefits Trust > Medicare Part D |
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HEALTH 2008! -- Registration Packet (PDF file)
You should make 4 copies of the progress chart.
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HEALTH 2008! -- Registration Packet (MS Word file)
You should make 4 copies of the progress chart.
Return to Wellness > Activities |
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Sample HIPAA Privacy Notice - for Accounts (PDF file)
Return to Health Benefits Trust > About |
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Sample HIPAA Privacy Notice - for Accounts (MS Word file)
Return to Health Benefits Trust > About |
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Auto Change Registration Form (PDF file)
Auto Change Registration Form (Word file)
These instructions are intended to assist you while making changes to your MIIA Automobile Fleet Schedule. As always, coverage is subject to the MIIA automobile contract language, terms, conditions and endorsements.
Return to Property & Liability > About |
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Special Events Coverage Application
Outside individuals or organizations that wish to use town facilities must fill out a Special Events Coverage application. Once completed, the member faxes or calls the information in to the town's Customer Service Representative (CSR) at the MIIA Property and Casualty Group. The CSR will advise the member of the cost of the special events coverage, which must be paid to the town by the user prior to using the facility. Questions about this special events coverage should be directed to your CSR.
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Releases for Voluntary School and Recreational Activities (PDF format)
Return to Property & Liability > About |
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Releases for Voluntary School and Recreational Activities (Word format)
Return to Property & Liability > About |
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Certificate of Insurance Expiration Notice
If operations continue beyond the expiration date(s) shown on the Certificate of Insurance, you must remind the contractor, lessee, and their appropriate insurance agent that a new Certificate of Insurance is required for the renewal at least 30 days before the actual expiration of the Certificate of Insurance. This form is a Certificate of Insurance Expiration Notice to be provided to a contractor, lessee and the appropriate insurance agent. For further information on the use of this form, refer to the Certificate of Insurance Manual.
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Order form - Vehicle Accident Kits
This kit is designed to be carried in all your registered motor vehicles and includes:
- Instructions in case of accident (printed on outside of envelope)
- Driver accident report (to be completed at scene)
- Witness card
- Pencil (not included with sample)
The kit will enable any driver involved in a motor vehicle accident to write the necessary information down immediately while details are fresh. When filled out, the "Driver Accident Report" form provides most of the information needed for the claim report to be filed with MIIA’s claims administrator.
Return to Property & Liability > About
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Employer's Guide to Massachusetts Workers' Compensation System (PDF file)
Return to Workers' Compensation > Main |
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Mandatory Workers' Compensation Poster (PDF file)
Return to Workers' Compensation > Main |
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Revised Massachusetts Workers’ Compensation Forms (PDF file)
Revised Massachusetts Workers’ Compensation Forms (Word file)
This form must be filed in triplicate as soon as 5 calendar days of lost time from work have occurred as a result of an alleged work-related injury or condition. The original must be filed with the Department of Industrial Accidents. A copy must be sent to the employee. The third copy must be filed with MIIA Member Services, 1 Federal Street, Boston, MA 02110 or just telephone the report into MIIA member services at 1-800-799-6442 and we handle all of the paperwork.
Return to Workers' Compensation > Main
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Supervisor's Report of Accident
Return to Workers' Compensation > Main |
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Sample Municipal Vehicle Use Policy (PDF file)
Sample Municipal Vehicle Use Policy (MS Word file)
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Sample Anti-Harassment Policy (PDF file)
Sample Anti-Harassment Policy (MS Word file)
The MCAD had recommended that, in addition to Sexual Harassment and EEO Policies, employers adopt general discriminatory harassment policies (or expand their existing Sexual Harassment Policy) to address harassment based on membership in protected classes other than gender. This sample policy is intended as a stand alone policy that members might choose to incorporate into their Personnel Policies. As with any new personnel policy, MIIA recommends that this sample be reviewed by legal counsel prior to adoption. |
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Prioritized Listing of Personnel Policies
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Sample Personnel Policies and Procedures (PDF file)
Sample Personnel Policies and Procedures (MS Word file)
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Zoning and Planning Board Decision Checklist
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Last Modified: Thursday, April 17, 2008
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