Get Form 103 The Commonwealth Of Massachusetts Dia Board - Massachusettsworkerscompensation

Filling out FORM 103 is an important step in the workers' compensation process in Massachusetts. This form serves as the insurer's notification of payment to the Department of Industrial Accidents, providing crucial information regarding benefits paid to employees.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the form and open it in your document editor.
2. In the first section, input the DIA Board number if known. This number helps in identifying your case within the system.
3. Indicate whether the insurance carrier is self-insured by marking 'Yes' or 'No.' Fill in the insurance carrier’s name and address in the fields provided.
4. For self-insurers, enter the self-insurer number. Then provide the name and contact number of the claim representative.
5. Record the insurer’s case file number for tracking purposes.
6. Answer whether the insurer received the First Report of Injury (Form 101). If yes, include the date received in the format mm/dd/yyyy.
7. Indicate if the insurer received a written claim for benefits from the employee. Provide the date received if applicable.
8. Enter the employee’s name in the format Last, First, MI and include their Social Security Number, which is voluntary but assists in processing.
9. Fill in the employee’s complete address, including street, city, state, and zip code.
10. Record the employee's date of birth in mm/dd/yyyy format and the employer’s name and address.
11. Document the date of injury along with the corresponding injury code, ensuring all body parts affected are properly logged.
12. Provide the dates regarding the employee's incapacity to earn wages, specifying the first and fifth days as needed.
13. If applicable, input the date of death of the employee and ensure any description of the injuries is clearly stated.
14. Enter the average weekly wage and select whether it is estimated or actual.
15. Document the details regarding payments made and the type of weekly compensation being paid.
16. The final section requires the insurer’s signature and the date the form was prepared.
17. After completing the form, review all entries for accuracy. Save your changes, and then you can download, print, or share the form as needed.

Complete your FORM 103 online today to ensure timely processing of your worker's compensation claims.