Complete Form List (alphabetical)
Addendum To Lump Sum Agreement: Vocational Rehabilitation Status (Form 116B)
Updated 8/2001
Affidavit In Support of Employee's Request For Speedy Conference Because Of Hardship (Form 132)
Updated 8/2001
Affidavit In Support Of Request For Waiver Of Filing Fee Under Section 11C (Form 112A)
Updated 8/2001
Affidavit of Employee in Application for Trust Fund Benefits (Form 170)
Updated - 11/2002
Affidavit of Exemption for Certain Corporate Officers (Form 153)
Affidavit of Indigence and Request for Waiver of Section 11A (2) Fees (Form 136)
Affidavits for Builders, Contractors, Plumbers, and Electricians
MGL c. 152, sec. 25C(6) states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with insurance coverage required." Additionally, MGL c. 152, sec. 35C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into a contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority."
Affidavits for General Businesses
MGL c. 152, sec. 25C(6) states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with insurance coverage required." Additionally, MGL c. 152, sec. 35C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into a contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority."
Agreement for Redeeming Liability by Lump Sum - for injuries before Nov. 1, 1986 (Form 117A)
Updated 8/2001
Agreement for Redeeming Liability by Lump Sum - for injuries on or after Nov. 1, 1986 (Form 117)
Updated 8/2001
Agreement that no Impartial Physician Report is Required (Form 121A)
Updated 8/2001
Agreement To Extend 180 Day Payment-Without-Prejudice Period (Form 105)
Updated 11/2001
Agreement To Pay Compensation (Form 113)
Updated 4/2009
Amendment, Suspension or Closure of Vocational Rehabilitation Plan (Form 152)
Updated 9/2009
Appeal Of Conference Order (Form 121)
Updated 8/2001
Appeal To Reviewing Board (Form 112)
Updated 8/2001
Application For Approval Of Utilization Review And Quality Assessment Program
Application To Serve As An Impartial Physician
Average Weekly Wage Computation Schedule (Form 127)
Updated 8/2005
Certified Vendor Quarterly Report for OEVR
Complaint of Improper Claims Handling Against an Insurer (Form 130)
Updated 8/2001
DOR Lien Release Request Guidance
Employee Biographical Data form (Form 160)
Updated 8/2001
Employee Claim Form -- With Instructions (Form 110)
Updated 5/21/2009
Employee Earning Report (Form 126)
Updated 8/2001
Employee's Hearing Memorandum - Form Revised - August 5, 2004 (Form 161)
Updated 8/2004
Employer Consent To Lump Sum Agreement (Form 116A)
Updated 8/2001
Employer First Report of Injury -- With Instructions (Form 101)
Updated 5/21/09
Guidelines for Payment under Section 36
Health Care Provider Complaint Form (Form 134)
Updated 7/2001
Individual Written Rehabilitation Program Form (Form 151)
Updated 8/200. You must SAVE this form to your Desktop before filling it out electronically.
Insurance Certification Request Form
Insurance Inquiry Form
File with Office of Insurance to check on coverage.
Insurer's Complaint For Modification, Discontinuance Or Recoupment Of Compensation (Form 108)
Updated 11/2001
Insurer's Hearing Memorandum (Form 162)
Updated 8/2004
Insurer's Notification Of Acceptance, Resumption, Termination Or Modification Of Weekly Compensation (Form 107)
Updated 8/2001
Insurer's Notification Of Denial (Form 104)
Updated 8/2001
Insurer's Notification Of Payment (Form 103)
Updated 9/04
Insurer's Notification Of Termination or Modification Of Weekly Compensation During Payment-Without-Prejudice Period (Form 106)
Updated 8/2001
Last Best Offer at Conference (Form 141)
Updated 8/2001
Lien Disclosure Form (Form 116C)
Updated 8/2001
Massachusetts Workers' Compensation COLA Data Form (CR-28)
Medical-Only Form (Form 118)
The Department of Industrial Accidents no longer supplies this form. For a medical-only claim you would use whatever form your insurance company has. This report is not sent to us.
Mileage Reimbursement Form for VR Providers
Motion For Expedited Conference (Form 125)
Updated 2/2007
Notice To Employees Posters
This mandatory poster is available in English, Cape Verdean, Chinese, Haitian Creole, Portuguese, Spanish and Vietnamese.
Notice Of Change/Appearance of Counsel (Form 114)
Upated 8/2001
Notification Of Arbitration Award (Form 124A)
Updated 8/2001
Notification Of Withdrawal Of Claim Or Complaint (Form 109)
Updated 8/2001
Petition For Approval Of Third Party Settlement Under M.G.L. c. 152, Section 15
Quarterly Report (Form 102)
There is no longer a requirement to file this form.
Referral For Mandatory Meeting
You must SAVE this form to your Desktop before filling it out electroncially.
Request For Section 37/37A Proceedings/Agreement Forms (Forms 122 and 123)
Form 122 Updated 11/2001
Form 123 Updated 11/2006Request For Section 46a Conference in Conjunction With Lump Sum Under Section 48 (Form 46A)
Request For Lump Sum Conference (Form 116)
Updated 5/21/2009
Request For Speedy Conference Because Of Hardship (Form 131)
Updated 8/2001
Request to Keeper of Records for file information
Section 15 Interactive Petition
Please note that to run this EXCEL Program you must have a version of EXCEL '97 or later and SAVE this document on your DESKTOP. If you do not, you may go to OpenOffice and download their free suite of tools that stands in for many software programs, including EXCEL. �� 2005 Commonwealth of Massachusetts
Section 15 Calculator Version 8.0
Please note that to run this EXCEL Program you must have a version of EXCEL '97 or later and SAVE this document on your DESKTOP. If you do not, you may go to OpenOffice and download their free suite of tools that stands in for many software programs, including EXCEL.�� 2005 Commonwealth of Massachusetts
Section 50 Interest Calculator - 3/09
Temporary Conference Memorandum Cover Sheet (Form 140)
Updated 8/2001
Third Party Claim/Notice Of Lien (Form 115)
Updated 8/2001
Utilization Review (UR) Agent Complaint Form (Form 133A)
Updated 10/2004