Complete Form List (alphabetical)

Addendum To Lump Sum Agreement: Vocational Rehabilitation Status (Form 116B)

Updated 7/2010
Affidavit In Support of Employee's Request For Speedy Conference Because Of Hardship (Form 132)

Updated 7/2010
Affidavit In Support Of Request For Waiver Of Filing Fee Under Section 11C (Form 112A)

Updated 7/2010
Affidavit of Employee in Application for Trust Fund Benefits (Form 170)

Updated - 7/2010
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."updated 7/2010
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."Updated 7/2010
Agreement for Redeeming Liability by Lump Sum - for injuries before Nov. 1, 1986 (Form 117A)

Updated 7/2010
Agreement for Redeeming Liability by Lump Sum - for injuries on or after Nov. 1, 1986 (Form 117)

Updated 7/2010
Agreement that no Impartial Physician Report is Required (Form 121A)

Updated 7/2010
Agreement To Extend 180 Day Payment-Without-Prejudice Period (Form 105)

Updated 7/2010
Agreement To Pay Compensation (Form 113)

Updated 7/2010
Amendment, Suspension or Closure of Vocational Rehabilitation Plan (Form 152)

Updated 7/2010
Appeal Of Conference Order (Form 121)

Updated 7/2010
Appeal To Reviewing Board (Form 112)

Updated 7/2010
Application To Become An Approved Utilization Review Agent

4/2011
Application To Serve As An Impartial Physician

7/2010
Average Weekly Wage Computation Schedule (Form 127)

Updated 7/2010
Certified Vendor Quarterly Report for OEVR

7/2010
Complaint of Improper Claims Handling Against an Insurer (Form 130)

Updated 7/2010
CR-28 - Massachusetts Workers' Compensation COLA Data Form
DOR Lien Release Request Guidance

7/2010
Employee Biographical Data form (Form 160)

Updated 7/2010
Employee Claim Form -- With Instructions (Form 110)

Updated 7/2010
Employee Earning Report (Form 126)

Updated 7/2010
Employee's Hearing Memorandum - Form Revised - August 5, 2004 (Form 161)

Updated 7/2010
Employer Consent To Lump Sum Agreement (Form 116A)

Updated 7/2010
Employer First Report of Injury -- With Instructions (Form 101)

Updated 7/2010
Guidelines for Payment under Section 36
Health Care Provider Complaint Form (Form 134)

Updated 7/2010
Individual Written Rehabilitation Program Form (Form 151)
Insurance Certification Request Form

January, 2012
Insurance Inquiry Form

File with Office of Insurance to check on coverage. Update 3/2013
Insurer's Complaint For Modification, Discontinuance Or Recoupment Of Compensation (Form 108)

Updated 7/2010
Insurer's Hearing Memorandum (Form 162)

Updated 7/2010
Insurer's Notification Of Acceptance, Resumption, Termination Or Modification Of Weekly Compensation (Form 107)

Updated 7/2010
Insurer's Notification Of Denial (Form 104)

Updated 7/2010
Insurer's Notification Of Payment (Form 103)

Updated 7/2010
Insurer's Notification Of Termination or Modification Of Weekly Compensation During Payment-Without-Prejudice Period (Form 106)

Updated 7/2010
Last Best Offer at Conference (Form 141)

Updated 7/2010
Lien Disclosure Form (Form 116C)

Updated 7/2010
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.
MGL Sec. 65B Appeal of Cancellation or Termination of Policy
Mileage Reimbursement Form for VR Providers

7/2010
Motion For Expedited Conference (Form 125)

Updated 7/2007
Notice of RFRs for Approval of VR Providers
Notice To Employees Posters

This mandatory poster is available in English, Arabic, Cape Verdean, Chinese, Haitian Creole, Khmer, Portuguese, Spanish and Vietnamese.
Notice Of Change/Appearance of Counsel (Form 114)

Upated 7/2010
Notification Of Arbitration Award (Form 124A)

Updated 7/2010
Notification Of Withdrawal Of Claim Or Complaint (Form 109)

Updated 7/2010
Petition For Approval Of Third Party Settlement Under M.G.L. c. 152, Section 15

Updated May, 2012
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 7/2010
Form 123 Updated 7/2010
Request For Lump Sum Conference (Form 116)

Updated 7/2010
Request For Section 46a Conference in Conjunction With Lump Sum Under Section 48 (Form 46A)

Updated 3/2011
Form 131 - Request For Speedy Conference Because Of Hardship

Updated 1/2012
Request to Keeper of Records for file information
Section 15 Interactive Petition v.2.62

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. Updated 5/2012
Section 15 Calculator Version 8.5

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 Updated 4/2012
Section 50 Interest Calculator - 3/09

Updated 7/2010
Conference Memorandum (Form 140)

Updated 8/23/2012
Third Party Claim/Notice Of Lien (Form 115)

Updated 7/2010
Utilization Review (UR) Agent Complaint Form (Form 133A)

Updated 10/2010
Verification of Massachusetts Workers' Compensation Coverage for Out-of-State Employers Operating in Massachusetts - Form 154

10/28/2010
W-9 - Request for Taxpayer Identification Number and Certification

Updated 7/2010

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Complete Form List (alphabetical)

Medical-Only Form (Form 118)

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