Get Ma Form 101 2001-2025

Filling out the MA Form 101 online can help ensure that your report of injury or fatality is submitted accurately and efficiently. This guide provides detailed, step-by-step instructions to assist users in completing the form correctly.

Follow the steps to successfully complete the MA Form 101 online

1. Press the ‘Get Form’ button to access the MA Form 101, allowing you to fill it out digitally.
2. Enter the employee’s name in the designated field using the format Last, First, MI. This step is essential for accurate identification of the affected individual.
3. Provide the employee’s home telephone number in the corresponding field to ensure communication regarding the injury.
4. Input the employee’s home address including number, street, city, state, and zip code for mail correspondence.
5. Fill in the employee’s Social Security number, remembering that disclosure is voluntary and aids in processing.
6. Specify the employee's sex by selecting M for Male or F for Female.
7. Select the marital status from the options presented: Single, Married, or other specified statuses.
8. Indicate the number of dependents that the employee has, as this information may be relevant for compensation calculations.
9. Record the date of hire in the specified format (mm/dd/yyyy) to document the employee's tenure.
10. Supply the date of birth also in mm/dd/yyyy format to further validate the employee's identity.
11. Enter the employee’s average weekly wage in the specified field, using an estimated amount if not known exactly.
12. Provide the employer's name clearly in the designated area to establish the reporting entity.
13. Input the employer's Federal Tax Identification Number for accurate record-keeping.
14. Fill out the employer's address for correspondence and record-keeping purposes.
15. Enter the employer's telephone number to ensure that communications can occur if needed.
16. Select the industry code that applies to the employer's business from the provided list.
17. Specify the name and telephone number of the workers' compensation insurance carrier, excluding local agents or administrators.
18. Indicate whether the employer is self-insured by selecting Yes or No and providing the necessary self-insurer number if applicable.
19. Record the date of injury in mm/dd/yyyy format to document when the incident occurred.
20. Answer whether the employee was injured on the employer's premises by selecting Yes or No.
21. If the injury occurred off-premises, provide the specific location details.
22. Record the first day of total or partial incapacity to earn wages, again in mm/dd/yyyy format.
23. Document the fifth day of total or partial incapacity to earn wages in the same date format.
24. If applicable, provide the date of death using mm/dd/yyyy format.
25. Describe the source of the injury (e.g., chemicals, machinery) to aid in understanding the incident.
26. Provide a brief explanation of how the injury or exposure occurred, including the body parts involved.
27. Document the name and position of the person to whom the injury was reported.
28. Record the date the injury was reported using mm/dd/yyyy format.
29. Fill in injury code(s) and body part code(s) based on the descriptions provided in the form.
30. List any witnesses to the injury, providing full names and indicating body part involvement.
31. Indicate whether the employee has returned to work with a Yes or No response.
32. If applicable, record the date the employee returned to work, keeping to the mm/dd/yyyy format.
33. Specify the employee's regular occupation to provide context for the reports.
34. Indicate if the employee has returned to their regular occupation with a Yes or No response.
35. Enter your name as the employer in the designated area.
36. State your title as the person completing the form.
37. Provide your signature in the designated area to authenticate the form.
38. Record the date prepared in mm/dd/yyyy format to complete the form.
39. Once all sections are completed, you can save any changes, download a copy for your records, print the form, or share it as necessary.

Complete your MA Form 101 online now to ensure timely reporting of workplace injuries or fatalities.