Massachusetts Lien Disclosure for Workers' Compensation

State:
Massachusetts
Control #:
MA-116C-WC
Format:
PDF
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Description

This is one of the official Workers' Compensation forms for the state of Massachusetts.

How to fill out Massachusetts Lien Disclosure For Workers' Compensation?

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FAQ

Most injuries that occur on the job are covered by workers' comp insurance, including accidents and illnesses caused by exposure to work activities, materials, and equipment. As soon as an employee suffers an occupational injury that is covered by workers' comp insurance, time is of the essence.

What happens if a claim is approved? If approved, employees will be notified about their compensation, which may cover costs such as medical expenses, disability, lost wages, and more. The employee can choose to accept the compensation amount via either a lump sum or a structured settlement.

How Long do I Have to File a Workers' Compensation Claim? You have four years from the time when you first discover your work-related injury or illness to file your claim.

When should an employee file a workers' comp claim? An employee should file a workers' compensation claim if injuries were sustained on the job or within the scope of employment. This includes occupational accidents, diseases, trauma injuries, or illness caused by exposure to work activities or chemicals.

You can also call our Office of Insurance for assistance at (617) 626-5480 or (617) 626-5481, or look up your employer's insurer online. If your employer doesn't have workers' compensation insurance, you will need to file a claim against the Workers' Compensation Trust Fund, which is part of the DIA.

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.

First Aid Treatment is Usually Not Enough. Injuries Outside the Office Are Covered. Injuries Outside the Scope of Employment. Cumulative Events and Injuries. Mental Health Conditions.

Reporting the injury. filing the actual claim with your employer, and. filing an application for adjudication of claim with the Workers' Compensation Appeals Board (WCAB).

Report the Injury or Illness Your employer has seven days to report the injury or illness to their insurance company and to DIA if you lose five or more days' wages on a form called the first report of injury, also known as Form 101.

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Massachusetts Lien Disclosure for Workers' Compensation