Massachusetts Workers' Compensation

Our most powerful wizard! These forms fill out almost completely saving you hours of tedious typing. The Workers’ Compensation Law section is designed to give you virtually all forms necessary to the practice of Workers’ Compensation Law.

Included are scores of automated official DIA forms, all of which are fully editable.
Included are Reports of Injuries, Notices of Claims, Insurers’ Notifications – virtually every official agency form – all capable of completion within minutes, and some within seconds! The program also contains Vocational Rehabilitation forms.

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Document List

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Correspondence - General

Letter - General

General

Application for Stay of Proceedings Pursuant to Rule 1.22 (2)
Case Intake Sheet
Client's Authorization for Medical Records
Deposition - Notice of Taking & Certificate of Service
DIA Board File Request Letter
DIA File Request
Employee's Authorization for Medical Records
Flat Fee Agreement - Employee
Guide for Calculating Loss-of-Function Benefits for Injuries Occurring on or After December 24, 1991
Guidelines for Disfigurement Other Than Scars for Injuries Occurring on or After December 24, 1991
Hourly Fee Agreement - Employee
Insurance Inquiry Form
Insurer Request Certification
Lien Release Requests
Maximum Compensation Rates (SAWW)
Mileage Expense Voucher
Motion to the Court and Affidavit
Notice to Employees
OEVR Rehabilitation Review Officers' Territories
Payment Voucher Input Form
Payment Voucher Instructions
Petition for Approval of Third Party Settlement
Referral Fee Acknowledgment
Schedule of Payments for Disfigurement for the Amputation of A Hand, Fingers or Parts Thereof
Subpoena Duces Tecum
Workers' Compensation COLA Data Form

Notary

Notary Jurat - Affidavit or Other Sworn or Affirmed Declaration
Notary Jurat - Attorney-Principal
Notary Jurat - Certified Copy
Notary Jurat - Individual with Oath or Affirmation
Notary Jurat - Individual without Oath or Affirmation
Notary Jurat - Representative of Business Entity

Official Forms

Form 046A - Request for Section 46A Conference
Form 101 - Employer's First Report of Injury or Fatality
Form 103 - Insurer's Notification of Payment
Form 104 - Insurer's Notification of Denial
Form 105 - Agreement to Extend 180 Day Payment Without Prejudice Period
Form 106 - Insurer's Notification of Termination or Modification of Weekly Compensation During Payment Without Prejudice Period
Form 107 - Insurer's Notification of Acceptance, Resumption or Termination or Modification of Weekly Compensation
Form 108 - Insurer's Complaint for Modification, Discontinuance or Recoupment of Compensation
Form 109 - Notification of Withdrawal of Claim or Complaint
Form 110 - Employee's Claim
Form 112 - Appeal to Reviewing Board
Form 112A - Affidavit in Support of Request for Waiver of Filing Fee Under Sec. 11c
Form 113 - Agreement to Pay Compensation
Form 114 - Notice of Change - Appearance of Counsel
Form 115 - Third Party Claim - Notice of Lien
Form 116 - Request for Lump Sum Conference
Form 116A - Consent of Employer to Lump Sum Settlement
Form 116B - Addendum to Lump Sum Settlement Agreement
Form 116C - Lien Disclosure Form
Form 117 - Agreement for Redeeming Liability By Lump Sum On or After 11-1-86
Form 117A - Agreement for Redeeming Liability By Lump Sum Before 11-1-86
Form 121 - Appeal of Conference Proceeding
Form 121A - Agreement That No Impartial Physician Report is Required
Form 122 - Request for Section 37 or 37A Hearing
Form 123 - Agreement Under Section 37 or 37A
Form 124A - Notification of Arbitration Award
Form 125 - (Employee's) Motion for Expedited Conference
Form 125 - (Insurer's) Motion for Expedited Conference
Form 126 - Employee's Earning Report
Form 130 - Complaint of Improper Claims Handling Against an Insurer
Form 131 - Request for Speedy Conference Because of Hardship
Form 132 - Affidavit in Support of Employee's Request for Speedy Conference Because of Hardship
Form 133A - Utilization Review Agent Complaint Form
Form 134 - Health Care Provider Complaint Form
Form 136 - Affidavit of Indigence and Request for Waiver of Section 11A(2) Fees
Form 140 - Temporary Conference Memorandum Cover Form
Form 141 - Last Best Offer At Conference
Form 153 - Affidavit of Exemption for Certain Corporate Officers
Form 160 - Employee Biographical Data
Form 161 - Employee's Hearing Memorandum
Form 162 - Insurer's Hearing Memorandum
Form 170 - Affidavit of Employee in Application for Trust Fund Benefits
Insurance Affidavit - Contractors
Insurance Affidavit - General Business

Vocational Rehabilitation

Affidavit of Compliance (Corporation)
Affidavit of Compliance (Unincorporated Entity)
Affidavit of Qualifications
Case Review Form (Provider Check-off Form)
Certified Vendor Quarterly Report for O.E.V.R.
Form 151 - Individual Written Rehabilitation Program
Form 152 - Amendment-Suspension or Closure of Vocational Rehabilitation Plan
Form TF-1 - Section 30H-VR Encumbrance Form
Form TF-2 - Section 30H-VR Payment Request
Form TF-3 - Section 30H-VR Payment Authorization
OEVR Referral Form
Rehabilitation Provider Certification Form