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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)
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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 7/2010Affidavits 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 7/2010Agreement for Redeeming Liability by Lump Sum - for injuries before Nov. 1, 1986 (Form 117A)
Updated 7/2010Agreement for Redeeming Liability by Lump Sum - for injuries on or after Nov. 1, 1986 (Form 117)
Updated 7/2010Agreement 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
4/2011Application 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
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Health Care Provider Complaint Form (Form 134)
Updated 7/2010 -
Individual Written Rehabilitation Program Form (Form 151)
Insurance Certification Request Form
January, 2012Insurance 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
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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 5/2012Section 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 4/2012Section 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
10/28/2010W-9 - Request for Taxpayer Identification Number and Certification
Updated 7/2010






