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Get MA Form 127 2013-2024

The Commonwealth of Massachusetts Department of Industrial Accidents FORM 127 DIA USE ONLY 1 Congress Street Suite 100 Boston Massachusetts 02114-2017 Info. Line 800 323-3249 ext. 7470 in Mass. Outside Mass. - 617-727-4900 ext. 7470 http //www. mass. gov/dia AVERAGE WEEKLY WAGE COMPUTATION SCHEDULE Print or Type 1. Employer s Name and Address 2. Insurer s Case File 3. DIA Board if known 5. of dependent children 6. of other dependents 7. Date of Injury mm/dd/yyyy 9. Date of Employment mm/dd/yyyy 8. Date of Disability mm/dd/yyyy 10. Has employee been certified by U*S* Veterans Administration for any type of disability Yes No Indicate only those wages earned by the injured worker during the 52 week period immediately preceding the accident. If the injured employee has worked for less than 52 weeks report wages from the time worked and for the remaining weeks on this schedule substitute wages of a fellow employee in the same class of employment who has worked for one year or more. Year Week Week Ending No* Month Day Gross Amount Before Taxes Week 12. Was room furnished to the employee Total 13. If tips or other benefits were earned describe and state value per week THIS IS A TRUE COPY OF THE PAYROLL RECORD OF THE ABOVE NAMED EMPLOYEE OR FELLOW EMPLOYEE IN THE SAME CLASS OF EMPLOYEMENT 14. Name of Fellow Employee if applicable 15. Employer/Preparer Signature Make any comments on the reverse side of this form or on a separate sheet. Line 800 323-3249 ext. 7470 in Mass. Outside Mass. - 617-727-4900 ext. 7470 http //www. mass. gov/dia AVERAGE WEEKLY WAGE COMPUTATION SCHEDULE Print or Type 1. Employer s Name and Address 2. Insurer s Case File 3. DIA Board if known 5. of dependent children 6. Employer s Name and Address 2. Insurer s Case File 3. DIA Board if known 5. of dependent children 6. of other dependents 7. Date of Injury mm/dd/yyyy 9. Date of Employment mm/dd/yyyy 8. Date of Disability mm/dd/yyyy 10. of other dependents 7. Date of Injury mm/dd/yyyy 9. Date of Employment mm/dd/yyyy 8. Date of Disability mm/dd/yyyy 10. Has employee been certified by U*S* Veterans Administration for any type of disability Yes No Indicate only those wages earned by the injured worker during the 52 week period immediately preceding the accident. Has employee been certified by U*S* Veterans Administration for any type of disability Yes No Indicate only those wages earned by the injured worker during the 52 week period immediately preceding the accident. If the injured employee has worked for less than 52 weeks report wages from the time worked and for the remaining weeks on this schedule substitute wages of a fellow employee in the same class of employment who has worked for one year or more. If the injured employee has worked for less than 52 weeks report wages from the time worked and for the remaining weeks on this schedule substitute wages of a fellow employee in the same class of employment who has worked for one year or more. Year Week Week Ending No* Month Day Gross Amount Before Taxes Week 12. Was room furnished to the employee Total 13. .

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