Get Ma Form 101 2013-2025

Filling out the MA Form 101 is a crucial step in reporting an injury or fatality within the workplace. This guide will assist you in understanding the various components of the form and the necessary information required for submission.

Follow the steps to complete the MA Form 101 online effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your online editor.
2. Begin by entering the employee’s name in the designated field, ensuring to include their last name, first name, and middle initial.
3. Provide the employee's home telephone number in the relevant section.
4. Fill in the home address of the employee including street number, street name, city, state, and zip code.
5. Enter the employee's social security number. Note that providing this number is voluntary but can aid in the processing of the report.
6. Specify the employee's native language code, indicating their preferred language for communication.
7. Indicate the marital status of the employee in the appropriate box provided.
8. List the employee's average weekly wage as an estimated figure.
9. Provide the employer’s name in the specified field.
10. Enter the number of dependents the employee has.
11. Input the employee's date of birth in the format of month, day, and year.
12. Document the date of hire for the employee.
13. Choose the employee's sex by selecting the appropriate option.
14. Record the employer's address, including street number, street name, city, state, and zip code.
15. Input the employer’s federal tax identification number.
16. Provide the employer’s contact telephone number.
17. Select the industry code that best represents the employer’s business.
18. Identify the workers' compensation insurance carrier along with their telephone number, ensuring that it is not the local agent or administrator.
19. Enter the employer’s policy number for workers' compensation insurance.
20. Indicate whether the employer is self-insured.
21. Document the date of the injury by entering it in the specified format.
22. Answer whether the employee was injured on the premises of the employer.
23. If the injury occurred off-premises, provide the location of the injury.
24. Fill in the first day of total or partial incapacity to earn wages.
25. Record the fifth day of total or partial incapacity to earn wages.
26. If applicable, note the date of death of the employee.
27. Specify the source of the injury, such as chemicals or machinery.
28. Provide a brief description of how the injury or exposure occurred, including the body parts involved.
29. List the person to whom the injury was reported, including their position.
30. Record the date the injury was reported.
31. Identify any witnesses to the injury, including their full names.
32. Indicate whether the employee has returned to work.
33. Document the date the employee returned to work.
34. Specify the employee’s regular occupation.
35. State whether the employee has returned to their regular occupation.
36. Fill in the preparer’s name, title, signature, and the date of preparation.
37. Finally, review the completed form for accuracy and save your changes. You may then download, print, or share the form as needed.

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