Form 106 - Insurer'S Notification Of Termination Or Modification Of Weekly Compensation During Payment Without Prejudice Period

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The Commonwealth of Massachusetts

FORM 106

DIA Board #

Department of Industrial Accidents – Department 106

(If Known):

1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017

Info. Line 800-323-3249 ext. 7470 in Mass. Outside Mass. - 617-727-4900 ext. 7470

INSURER’S NOTIFICATION OF TERMINATION OR

MODIFICATION OF WEEKLY COMPENSATION DURING

PAYMENT WITHOUT PREJUDICE PERIOD

CHECK ONE BOX: TERMINATION

MODIFICATION

FILE ONLY WHEN PAYMENT HAS BEEN MADE WITHIN 14 DAYS. AT LEAST 7 DAYS WRITTEN NOTICE MUST

BE GIVEN TO EMPLOYEE OF THE INTENT TO STOP PAYMENTS, UNLESS BASED ON ACTUAL INCOME OF EMPLOYEE

1. Insurance Carrier’s Name and Address:

2. Self-insured?:

Yes

If Yes Please Give Self-insurer Number:

3. Name & Address of Insurer’s Attorney:

4. Telephone Number of Insurer’s Attorney:

5. Claim Representative’s Name:

6. Claim Representative’s Tel. Number & Ext.:

7. Insurer’s Case File Number:

8. Did Insurer Receive First Report of Injury (Form 101);

Yes

No - If Yes - Date Received (mm/dd/yyyy):

9. Employee’s Name (Last, First, MI

10. Employee’s Social Security Number*:

)

11. Employee’s Address (No. and Street, City, State, Zip Code):

12. Date of Birth (mm/dd/yyyy):

13. Date of Injury (mm/dd/yyyy):

14. First Day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy): 15. Fifth Day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy):

16. Employer’s Name & Address (No. and Street, City, State, Zip Code):

17. Employer’s Federal Tax ID #:

18. Employee Returned to Work:

Yes

No (If Yes - 7 days written notice not required)

If Yes - Date of Return (mm/dd/yyyy):

Employee’s Income $________________

19. Specify grounds for termination and give a brief statement of the specific facts supporting the grounds for termination.

Failure to do so may cause loss of defenses under M.G.L. c 152, Sections 7(1) and 7(2).

No Personal Injury _____________________________________________________________________________________________________

No Injury Arising Out of and in the Course of Employment _____________________________________________________________________

No Disability __________________________________________________________________________________________________________

No Causal Relationship Between Personal Injury and Disability _________________________________________________________________

Lack of Jurisdiction ____________________________________________________________________________________________________

Lack of Notice ________________________________________________________________________________________________________

Late Claim ___________________________________________________________________________________________________________

Other (Specify) ________________________________________________________________________________________________________

Use additional space on back of form if needed.

20. Last Date Through Which Payment Will Be Made (mm/dd/yyyy):

21. Date of Notification of Termination or Modification to the

Employee (mm/dd/yyyy):

22. If this is a Modification rather than a Termination, please state the grounds and factual basis for the Modification and the prior rate(s) of weekly

compensation paid and the Modification rate(s) of weekly compensation.

Basis for Modification (use reverse side if needed).

Prior Rate(s):

$_____________________ $_____________________

Modified Rate(s):

$_____________________ $_____________________

23. Insurer’s Signature:

24. Date Prepared (mm/dd/yyyy):

*Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents.

Form 106

Revised 7/2013- Reproduce as needed.

Please Print Clearly or Type. Unreadable forms will be returned.