State of Massachusetts Forms in Word

Massachusetts Workers’ Compensation Forms in Microsoft Word

Massachusetts Form Number

Form Title


Buy Now

Form 46A Request For Section 46A Conference in Conjunction With Lump Sum Under Section 48 $12.99
Form 101 Employer’s First Report of Injury/Fatality $12.99
Form 103 Insurer’s Notification of Payment $12.99

Form 104 Insurer’s Notification of Denial $12.99

Form 105 Agreement to Extend 180 Day Payment-Without-Prejudice Period $12.99

Form 106 Insurer’s Notification of Termination or Modification of Weekly Compensation During Payment-Without-Prejudice Period $12.99

Form 107 Insurer’s Notification of Acceptance, Resumption, Termination or Modification of Weekly Compensation $12.99

Form 108 Insurer’s Complaint for Modification, Discontinuance or Recoupment of Compensation $12.99

Form 109 Notification of Withdrawal of Claim or Complaint $12.99

Form 110 Employee Claim $12.99

Form 112 Appeal to Reviewing Board $12.99

Form 112A Affidavit in Support of Request for Waiver of Filing Fee Under Section 11C $12.99

Form 113 Agreement to Pay Compensation $12.99

Form 114 Notice of Change/Appearance of Counsel $12.99

Form 115 Third Party Claim/Notice of Lien $12.99

Form 116 Request for Lump Sum Conference $12.99

Form 116A Employer Consent to Lump Sum Agreement $12.99

Form 116B Addendum to Lump Sum Agreement: Vocational Rehabilitation Status $12.99

Form 116C Lien Disclosure Form $12.99

Form 117 Agreement for Redeeming Liability by Lump Sum for Injuries On or After Nov. 1, 1986 $12.99

Form 117A Agreement for Redeeming Liability by Lump Sum for Injuries Before Nov. 1, 1986 $12.99

Form 121 Appeal of Conference Order $12.99

Form 121A Agreement That No Impartial Physician Report is Required $12.99

Form 122& Request for Sections 37 Proceedings/Agreement   $12.99

Form 123 Request for Sections 37A Proceedings/Agreement   $12.99

Form 124A Notification of Arbitration Award $12.99

Form 125 Motion for Expedited Conference $12.99

Form 126 Employee Earning Report $12.99

Form 127 Average Weekly Wage Computation Schedule $12.99

Form 130 Complaint of Improper Claims Handling Against an Insurer $12.99

Form 131 Request For Speedy Conference Because Of Hardship $12.99

Form 132 Affidavit in Support of Employee’s Request for Speedy Conference Because of Hardship $12.99

Form 133A Utilization Review (UR) Agent Complaint $12.99

Form 134 Health Care Provider Complaint $12.99

Form 136 Affidavit of Indigence and Request for Waiver of Sec. 11A(2) Fees $12.99

Form 140 Temporary Conference Memorandum Cover Sheet $12.99

Form 141 Last Best Offer at Conference $12.99

Form 151 Individual Written Rehabilitation Program Form $12.99

Form 152 Amendment/Suspension or Closure of Vocational Rehabilitation Plan $12.99

Form 153 Affidavit of Exemption for Certain Corporate Officers or Directors $12.99

Form 154 Verification of Massachusetts Workers’ Compensation Coverage for Out-Of-State Employers Operating in Massachusetts $12.99

Form 160 Employee’s Biographical Data Sheet $12.99

Form 161 Employee’s Hearing Memorandum $12.99

Form 162 Insurer’s Hearing Memorandum $12.99

Form 170 Affidavit of Employee in Application for Trust Fund Benefits $12.99