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WORKERS' COMPENSATION MASSACHUSETTS CONSTRUCTION CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM APPLICATION Insured Federal Employers ID No. Address City Policy No. NOTICE: Effective Date State Carrier.

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If your Massachusetts workers' compensation claim is denied, you will receive an insurer's notification of denial, or Form 104, by certified mail. The form should include an explanation of why your employer's insurer is denying your claim.

If you were injured at work, you may be eligible for workers' compensation benefits. If you qualify, you can receive payments to partially replace your paycheck and for medical care related to your injury. You may also be eligible for vocational rehabilitation if you need help getting back to work.

You can also call our Office of Insurance for assistance at (617) 626-5480 or (617) 626-5481, or look up your employer's insurer online. If your employer doesn't have workers' compensation insurance, you will need to file a claim against the Workers' Compensation Trust Fund, which is part of the DIA.

Weekly TTI payments are calculated as 60% of your average weekly wage before your injury or illness, subject to a maximum and minimum based on the statewide average weekly wage (SAWW) at the time of your injury. You'll receive the full amount of your pre-injury wages if they were less than the minimum.

During this time period, you may receive a Form 106, “Insurer's Notification of Termination or Modification of Weekly Compensation During Payment-Without-Prejudice Period.” If you receive this form, it means the insurer has decided to modify or terminate your workers' compensation benefits.

Form 105 is an Agreement to Extend the 180 Day Payment Without Prejudice Period (PWOP). Workers' Compensation insurers may send this form to you if you are injured and have not gotten an attorney.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232