Get Ma Form 126 2019-2025

The MA Form 126 is a critical document for employees in Massachusetts who need to report their earnings while receiving workers' compensation benefits. This guide provides clear steps to help users navigate the process of completing the form online effectively.

Follow the steps to fill out the MA Form 126 online

1. Click the ‘Get Form’ button to obtain the form and open it in your online document editor.
2. Enter the employee’s name in the format 'Last, First, MI' in the designated field.
3. Provide the employee’s social security number in the specified field; note that disclosing this number is voluntary but can aid in processing.
4. Fill in the date of injury in the 'mm/dd/yy' format.
5. Input the employee’s mailing address, ensuring you include the complete address including city, state, and zip code.
6. If the residential address differs from the mailing address, provide it in the next field.
7. Include the employee’s attorney’s name and their address if applicable.
8. If known, enter the DIA board number in the corresponding field.
9. Provide the employee's date of birth in 'mm/dd/yy' format.
10. Report your earnings by listing each week’s gross amount before taxes in the appropriate fields. Ensure you indicate the week number and the month.
11. List the name and address of the employer or any other payer of wages. If you have additional employers, list them on the back of the form.
12. If applicable, mark the box to indicate that you have not received earnings during the entitlement period for workers' compensation benefits.
13. Sign the form in the employee’s signature field.
14. Input the date signed in 'mm/dd/yyyy' format.
15. Finally, ensure the completed form is mailed to the insurer at the address specified.

Complete your MA Form 126 online today to ensure your benefits continue without interruption.