Form 107 - Insurer'S Notification Of Acceptance, Resumption Or Termination Or Modification Of Weekly Compensation - The Commonwealth Of Massachusetts Department Of Industrial Accidents
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1
2The Commonwealth of Massachusetts
FORM 107
DIA Board #
Department of Industrial Accidents – Department 107
(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 ACCEPTANCE, RESUMPTION
OR TERMINATION OR MODIFICATION OF WEEKLY COMPENSATION
CHECK ONE BOX:
ACCEPTANCE
RESUMPTION
TERMINATION
MODIFICATION
USE FORM 106 AS NOTICE TO TERMINATE OR MODIFY WEEKLY PAYMENTS BEING MADE WITHOUT PREJUDICE
§
UNDER M.G.L., CHAPTER 152
8(1). Please Print or Type.
1. Insurance Carrier’s Name and Address:
2. Self-insured?:
Yes
No
If Yes Please Give Self-insurer Number:
I
3. Name & Address of Insurer’s Attorney:
4. Telephone Number of Insurer’s Attorney:
N
S
U
5. Claim Representative’s Name:
6. Claim Representative’s Tel. Number & Ext.:
R
E
R
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):
E
13. Date of Injury (mm/dd/yyyy):
M
P
L
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):
O
Y
16. Employer’s Name & Address (No. and Street, City, State, Zip Code):
17. Employee’s Average Weekly Wage:
E
E
$
Actual
Estimated
18. Employee Returned to Work:
Yes
No
19. Date of Resumption, Modification or Termination
If Yes - Date of Return (mm/dd/yyyy):
(mm/dd/yyyy):
20.
This is a Notice of Initial Acceptance of a Claim (ATTACH FORM 113).
This is a Resumption/Modification of Payment of a Case Previously Accepted.
This is a Resumption of Payment of a Case within the Payment Without Prejudice Period.
This is a Resumption/Modification of Payment under §30G.
Type of Compensation
Former Weekly
Resumed or Modified
Resumed or Modified
Compensation Rate
Weekly Compensation Rate
A.
Temporary, Total Incapacity (§34)
$
$
B
B.
Permanent & Total Incapacity (§34A)
$
$_________________
E
C.
Partial Incapacity (§35)
$
$_________________
N
D.
Dependency Coverage (§35A)
$
$_________________
E
E.
Survivor’s Benefits (§31)
F
$
$
I
21. If the Insurer is Terminating or Suspending Payment of Weekly Benefits without the Assent of the Employee or the Dept. of Industrial Accidents,
T
set out the Applicable Statutory Section and Factual Basis Therefore (continue on the reverse side if needed):
S
22. If the Insurer is Terminating or Modifying with the Assent of the Compensation Recipient, the Recipient’s Signature is Required.
Signature of Recipient:
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 107
Revised 7/2013- Reproduce as needed.
Please Print Clearly or Type. Unreadable forms will be returned.
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