Form 101 - Employer'S First Report Of Injury
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1
2FORM 101
The Commonwealth of Massachusetts
DIA USE ONLY
Department of Industrial Accidents – Department 101
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470
Print Form
EMPLOYER’S FIRST REPORT OF INJURY
OR FATALITY
THIS FORM MUST BE FILED BY THE EMPLOYER IN THE EVENT OF AN INJURY THAT RESULTS IN DEATH
OR FIVE OR MORE CALENDAR DAYS OF TOTAL OR PARTIAL INCAPACITY FROM EARNING WAGES.
INSTRUCTIONS AND CODES ON THE REVERSE SIDE - Please Print Legibly or Type - Unreadable forms will be returned.
3. Social Security Number*:
1. Employee’s Name (Last, First, MI):
2. Home Telephone Number:
4. Sex:
E
M
F
M
P
5. Home Address (No., Street, City, State & Zip Code):
5a. Native Language Code:
6. Marital Status:
7. No. of Dependents:
L
M
S
O
Other:________________
Y
8. Date of Hire (mm/dd/yyyy):
9. Date of Birth (mm/dd/yyyy):
10. Average Weekly Wage:
E
$
Estimated
Actual
E
11. Employer’s Name:
12. Federal Tax I.D. Number:
E
13. Employer’s Address (No., Street, City, State & Zip Code):
14. Employer’s Telephone Number:
M
P
L
15. Industry Code (See Reverse Side):
O
16. Workers’ Compensation Insurance Carrier and Tel. No.
:
17. W.C. Policy Number:
(NOT LOCAL AGENT/ADMINISTRATOR)
Y
E
R
19. Business Type :
Service
Wholesale
Mfg.
18. Self-Insured?
Yes
No
Retail
Other ________________________
If Yes, Self-Insurer Number:
20a. Insurer’s Case/Claim File No.:
20. DATE OF INJURY (mm/dd/yyyy):
22. Location of Injury if not on Employer’s Premises:
21. Was Employee Injured on Employer’s Premises?
Yes
No
I
N
23. FIRST day of Total or Partial Incapacity to Earn Wages
24. FIFTH day of Total or Partial Incapacity to Earn Wages
J
(mm/dd/yyyy):
(mm/dd/yyyy):
U
R
25. If Employee has Died, Date of Death (mm/dd/yyyy):
26. Source of Injury (Chemicals, Machinery, etc.):
Y
I
27. Briefly Describe How Injury/Exposure Occurred and Body Part(s) involved:
N
F
O
R
M
28. Person to Whom Injury was Reported (list position):
29. Date Reported (mm/dd/yyyy):
30. Date Reported as work related
A
(mm/dd/yyyy):
T
I
32. Witness(es) to Injury - Give Full Name(s), if none state as such:
31. Injury Code(s)
Body Part Code(s)
O
a.
to body part
a.
N
b.
to body part
b.
c.
to body part
c.
33. Has Employee Returned to Work?
Yes
No
34. Date Employee Returned to Work(mm/dd/yyyy):
35. Employee’s Regular Occupation:
36. Has Employee Returned to Regular Occupation:
Yes
No
37. PREPARER’S Name (SEE INSTRUCTIONS ON REVERSE SIDE):
38. PREPARER’S Title:
P
R
E
P
39
PREPARER’S Signature (SEE INSTRUCTIONS ON REVERSE SIDE
40. Date Prepared (mm/dd/yyyy):
40a. PREPARER’S e-mail address:
.
):
A
R
E
R
-
*Disclosure of Social Security Number is Voluntary. It will aid in the processing of your report.
Form 101
Revised 7/2010 - Reproduce as needed.
THIS FORM DOES NOT CONSTITUTE AN EMPLOYEE’S CLAIM FOR BENEFITS UNDER WORKERS’ COMPENSATION.
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