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Get MA Form 101 2013-2024

49 ext. 7470 in Mass. Outside Mass. - 617-727-4900 ext. 7470 http://www.mass.gov/dia EMPLOYER S FIRST REPORT OF INJURY OR FATALITY THIS FORM MUST BE FILED BY THE EMPLOYER IN THE EVENT OF AN INJURY THAT RESULTS IN DEATH OR FIVE OR MORE CALENDAR DAYS OF TOTAL OR PARTIAL INCAPACITY FROM EARNING WAGES. INSTRUCTIONS AND CODES ON THE REVERSE SIDE - Please Print Legibly or Type - Unreadable forms will be returned. E M P L O Y E E 1. Employee s Name (Last, First, MI): 2. Home Telephone Number: 5.

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