EasyFillForms - Workers' Compensation

Massachusetts Department of Industrial Accidents Forms on Disc

Form #	Revision Date	Pages	Title
101	Feb-93	1	Employer's First Report of Injury or Fatality
103	Feb-93	1	Insurer's Notification of Payment
104	Feb-93	1	Insurer's Notification of Denial
105	Feb-93	1	Agreement to Extend 180 Day Payment-Without-Prejudice Period
106	Feb-93	1	Insurer's Notification of Termination of Modification of Weekly Compensation During Payment-Without-Prejudice
107	Feb-93	1	Insurer's Notification of Acceptance, Resumption, Termination, or Modification of Weekly Compensation
108	Feb-93	1	Insurer's Complaint for Modification Discontinuance or Recoupment of Compensation
109	Feb-93	1	Notification of Withdrawal of Claim or Complaint
110	Feb-93	1	Employee's Claim
112	Feb-93	2	Appeal to Reviewing Board
112A	Feb-93	2	Affidavit in Support of Request for Waiver of Filing Fee Under s.11C
113	Feb-93	1	Agreement to Pay Compensation
114	Feb-93	1	Notice of Change/Appearance of Counsel
115	Feb-93	1	Third Party Claim/Notice of Lien
116	Feb-93	1	Request For Lump Sum Conference
116A	Feb-93	1	Employer Consent to Lump Sum Agreement
116B	Feb-93	1	Addendum to Lump Sum Agreement Pursuant to c.398, S.75 of the Acts of 1991, Effective December 24, 1991 Vocational Rehabilitation Status
116C	Feb-93	1	Lien Disclosure Form
121	Feb-93	1	Appeal of Conference Proceeding
122	Aug-98	2	Request for Section 37/37A Proceedings/Agreement Form
123	Mar-99	1	Agreement Under Section 37 or 37A
126	Mar-99	1	Employee's Earning Report
131	Feb-93	1	Request for Speedy Conference Because of Hardship
132	Feb-93	2	Affidavit in Support of Employee's Request for Speedy Conference Because of Hardship
133A	Mar-99	2	Utilization Review (UR) Agent Complaint Form
134	Jan-98	2	Health Care Provider Complaint Form
136	Jul-96	2	Affidavit of Indigence and Request for Waiver of §11A(2) Fees

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