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Massachusetts Form Center -

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Form

Description

101.pdf Employer First Report of Injury / Fatality -Must contact state to file FROI
101instr.pdf Employer First Report of Injury / Fatality - Directions
101-instruct-spanish.pdf Employer First Report of Injury/Fatality - Directions (Spanish)
101_print.pdf First Report of Injury or Illness - This form is ONLY for internal use. DO NOT file this form with the state. You must file online.
19.pdf Section 19 Agreement
46A.pdf Request for Section 46A Conference in Conjunction with Lump Sum under Section 48
50x.pdf Assessment Amendment
51x.pdf Assessment Amendment
103.pdf Insurer's Notification of Payment
104.pdf Insurer's Notification of Denial
105.pdf Agreement to Extend 180 Day Payment-without-Prejudice Period
106.pdf Insurer's Notification of Termination or Modification of Weekly Compensation During Payment-without-Prejudice Period
107.pdf Insurer's Notification of Acceptance, Resumption, Termination or Modification of Weekly Compensation
108.pdf Insurer's Complaint for Modification, Discontinuance or Recoupment of Compensation
109.pdf Notification of Withdrawal of Claim or Complaint
110.pdf Employee Claim
110-instruct-english.pdf Form 110 Directions
110-instruct-spanish.pdf Form 110 Directions (Spanish)
112.pdf Appeal to Reviewing Board
112a.pdf Affidavit in Support of Request for Waiver of Filing Fee under Section 11C
113.pdf Agreement to Pay Compensation
114.pdf Notice of Change/Appearance of Counsel
115.pdf Third Party Claim / Notice of Lien
116.pdf Request for Lump Sum Conference
116a.pdf Employer Consent to Lump Sum Agreement
116b.pdf Addendum to Lump Sum Agreement: Vocational Rehabilitation Status
dor-lien.pdf DOR Lien Request - Workers' Compensation Lien Release Requests
116c.pdf Lien Disclosure Form
117.pdf Agreement for Redeeming Liability by Lump Sum - for injuries on or after Nov. 1, 1986
117a.pdf Agreement for Redeeming Liability by Lump Sum - for injuries before Nov. 1, 1986
121.pdf Appeal of Conference Order
121a.pdf Agreement that No Impartial Physician Report is Required
eligibility-statement.pdf Application to Serve as an Impartial Physician- Statement of Eligibility to Serve on Roster of Impartial Physicians
122.pdf Request for Section 37/37A Proceedings / Agreement Forms
123.pdf Agreement under Section 37 or 37A
124a.pdf Notification of Arbitration Award
125.pdf Motion for Expedited Conference
126.pdf Employee Earning Report
127.pdf Average Weekly Wage Computation Schedule
130.pdf Complaint of Improper Claims Handling Against an Insurer
131.pdf Request for Speedy Conference because of Hardship
132.pdf Affidavit in Support of Employee's Request for Speedy Conference because of Hardship
133a.pdf Utilization Review (UR) Agent Complaint
134.pdf Health Care Provider Complaint
136.pdf Affidavit of Indigence and Request for Waiver of Section 11A (2) Fees
140.pdf Conference Memorandum
141.pdf Last Best Offer at Conference
151.pdf Individual Written Rehabilitation Program Form
152.pdf Amendment/Suspension or Closure of Vocational Rehabilitation Plan
153.pdf Affidavit of Exemption for Certain Corporate Officers
154.pdf Verification of Massachusetts Workers' Compensation Coverage for Out-of-State Employers Operating in Massachusetts
160.pdf Employee's Biographical Data Sheet
161.pdf Employee's Hearing Memorandum
162.pdf Insurer's Hearing Memorandum
170.pdf Affidavit of Employee in Application for Trust Fund Benefits
aff_builders.pdf Workers' Compensation Insurance Affidavit: Builders / Contractors / Electricians / Plumbers
aff_general.pdf Workers' Compensation Insurance Affidavit: General Businesses
cr28.pdf Workers' Compensation COLA Data Form
Ins_cert.pdf Insurer Request Certification Form
Insurance-Inquiry.pdf Insurance Inquiry Form
65b-form.pdf Appeal of Cancellation of Policy
KORRequest.pdf DIA File Request
OEVRReferralForm.pdf Referral For Mandatory Meetings Held under G.L.C.152, 30g
OEVRTravelVoucher.pdf Mileage Voucher
ohp_app.pdf Application to Become an Approved Utilization Review Agent and Affidavit of Compliance Form
VR_CHART.pdf Certified Vendor Quarterly Report (OEVR)
vr_recert.pdf Certification for Approval of Vocational Rehabilitation Providers
oevr-certify-renewal.pdf Recertification for Vocational Rehabilitation Providers
Vr_review.pdf Case Review Form
vr_tf_forms.pdf Section 30H-VR Encumbrance Form
vr-english.pdf Brochure - Office of Education and Vocational Rehabilitation (OEVR) Return to Work Assistance
vr_voucher_numbers.pdf Payment Voucher Input Form
POSTER.pdf POSTER - Notice To Employees Poster
POSTER-spanish.pdf POSTER - Notice To Employees Poster (Spanish)
er-guide-english.pdf BROCHURE - Employer's Guide to the Massachusetts Workers' Compensation System
employer-guide-spanish.pdf BROCHURE - Employer's Guide to the Massachusetts Workers' Compensation System (Spanish)
ee-english.pdf BROCHURE - Massachusetts Workers' Compensation Guide for Injured Workers
ee-guide-spanish.pdf BROCHURE - Massachusetts Workers' Compensation Guide for Injured Workers (Spanish)
ee_english.pdf BROCHURE - Understanding Workers' Compensation
ee_spanish.pdf BROCHURE - Understanding Workers' Compensation (Spanish)