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Get MA Form 127 2005

114-2017 Info. Line 800 323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 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: 4. Employee’s Name and Address: 6. # of other dependents: 7. Date of Injury (mm/dd/yyyy): 8. Date of Disability (mm/dd/yyyy): 9. Date of Employment (mm/dd/yyyy): 10. Has employee been certified by U.S. Vete.

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