Get Form 108 - Mass.gov - Mass

Filling out the Form 108 is an important step for insurers initiating a request for modification, discontinuance, or recoupment of compensation in Massachusetts. This guide provides a straightforward approach to help you accurately complete the form online, ensuring compliance with regulations.

Follow the steps to fill out the Form 108 online effectively.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editing platform.
2. In the section for the insurer's details, provide the name and address of the insurance carrier clearly.
3. Specify if the insurer is self-insured by selecting 'Yes' or 'No'. If 'Yes', include the self-insurer number.
4. Enter the name and address of the insurer's attorney, along with their telephone number.
5. Fill in the claim representative's name and their telephone number with extension.
6. Input the insurer's case file number in the designated field.
7. Indicate whether the insurer received the First Report of Injury (Form 101). If 'Yes', provide the date it was received in the specified format.
8. Enter the employee's details, including their name and social security number; note that providing the social security number is voluntary.
9. Fill in the employee's complete address, including street, city, state, and zip code.
10. Record the employee's date of birth and the date of injury.
11. List the first day that the employee could not earn wages due to incapacity.
12. Provide the name, address, and telephone number of the employee's attorney.
13. Input the employer's name and address.
14. Select the appropriate box indicating whether this is a request to modify, discontinue, or recoup weekly compensation, and attach the necessary documentation as per the relevant regulations.
15. State the specific basis for your complaint in detail. You may continue on the reverse side if additional space is needed.
16. Sign the form where indicated and enter the date prepared.
17. Once completed, save your changes, and you can download, print, or share the form as needed.

Complete your Form 108 online today to streamline your processing.