Get Mass Dia Form 101

The Mass Dia Form 101 is essential for reporting workplace injuries or fatalities in Massachusetts. This guide will provide you with clear, step-by-step instructions on how to complete the form accurately and efficiently online.

Follow the steps to fill out the Mass Dia Form 101 online:

1. Press the ‘Get Form’ button to access the Mass Dia Form 101 and open it in your preferred online editor.
2. Begin by entering the employee’s name in the format of last name, first name, and middle initial in the designated field.
3. Next, provide the employee’s home telephone number to ensure contact information is accurate.
4. Fill in the home address of the employee, including street number, street name, city, state, and zip code.
5. Record the date of hire in the specified format (mm/dd/yyyy) to establish employment history.
6. Input the employer's name and their federal tax identification number clearly.
7. Include the employer's address, similar to the employee's, ensuring all details are correct.
8. Provide the employer's telephone number for any follow-up communications.
9. Specify the date of the injury in the required format (mm/dd/yyyy).
10. Indicate whether the employee was injured on the employer's premises by selecting 'Yes' or 'No'.
11. Document the first day of total or partial incapacity to earn wages, again using the format (mm/dd/yyyy).
12. Briefly describe how the injury or exposure occurred, mentioning any body parts involved.
13. State the name and position of the person to whom the injury was reported.
14. Fill in the employee's Social Security number, sex, marital status, and number of dependents, ensuring this information is up-to-date.
15. Provide the employee’s date of birth and their average weekly wage, estimated or actual.
16. Complete the industry code and workers’ compensation policy number sections accurately.
17. Claim the self-insured status if applicable, and provide the self-insurer number if necessary.
18. Complete the business type, selecting from the provided options.
19. Record the location of the injury if it was not on the employer's premises.
20. If applicable, enter the date of death of the employee in the required format (mm/dd/yyyy).
21. Document the fifth day of incapacity to earn wages.
22. Indicate the date reported and if the injury was reported as work-related.
23. Fill in the injury code(s) for the body parts affected.
24. List any witnesses to the injury, providing full names.
25. Indicate whether the employee has returned to work and provide the date if applicable.
26. Document the employee’s regular occupation and confirm whether they have returned to their regular occupation.
27. Complete the employer's name and title in the respective boxes.
28. The employer must sign in the designated box and indicate the date prepared.
29. Finally, review all completed sections for accuracy, then save changes, download, print, or share the completed form.

Complete your Mass Dia Form 101 online today for a seamless submission.