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Massachusetts Department of Industrial Accidents Forms

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Form A-1 Statement of Eligibility to Serve on Roster of Impartial Physicians - Massachusetts PDF

Form A-1 Statement of Eligibility to Serve on Roster of Impartial Physicians - Massachusetts
Certificate of Eligibility Form Massachusetts Legal Forms Certificate Template United States Legal Forms
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Form 19 Section 19 Agreement - Massachusetts PDF

Form 19 Section 19 Agreement - Massachusetts
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OEVR Form 152 Amendment, Suspension, or Closure of Vocational Rehabilitation Plan - Massachusetts PDF

OEVR Form 152 Amendment, Suspension, or Closure of Vocational Rehabilitation Plan - Massachusetts
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Form 19A Section 19a Medical Mediation Agreement - Massachusetts PDF

Form 19A Section 19a Medical Mediation Agreement - Massachusetts
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Form 153 Affidavit of Exemption for Certain Corporate Officers or Directors - Massachusetts PDF

Form 153 Affidavit of Exemption for Certain Corporate Officers or Directors - Massachusetts
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Form 114 Notice of Change/Appearance of Counsel - Massachusetts PDF

Form 114 Notice of Change/Appearance of Counsel - Massachusetts
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Form 123 Agreement Under Section 37 or 37a - Massachusetts PDF

Form 123 Agreement Under Section 37 or 37a - Massachusetts
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Form 160 Employee Biographical Data - Massachusetts PDF

Form 160 Employee Biographical Data - Massachusetts
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Form 161 Employee's Hearing Memorandum - Massachusetts PDF

Form 161 Employee's Hearing Memorandum - Massachusetts
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Form 107 Insurer's Notification of Acceptance, Resumption, Termination or Modification of Weekly Compensation - Massachusetts PDF

Form 107 Insurer's Notification of Acceptance, Resumption, Termination or Modification of Weekly Compensation - Massachusetts
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Form 131 Request for Speedy Conference Because of Hardship - Massachusetts PDF

Form 131 Request for Speedy Conference Because of Hardship - Massachusetts
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Form 151 Individual Written Rehabilitation Program - Massachusetts PDF

Form 151 Individual Written Rehabilitation Program - Massachusetts
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Form 125 Motion for Expedited Conference - Massachusetts PDF

Form 125 Motion for Expedited Conference - Massachusetts
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Form 115 Third Party Claim/Notice of Lien - Massachusetts PDF

Form 115 Third Party Claim/Notice of Lien - Massachusetts
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Form 132 Affidavit in Support of Employee's Request for Speedy Conference Because of Hardship - Massachusetts PDF

Form 132 Affidavit in Support of Employee's Request for Speedy Conference Because of Hardship - Massachusetts
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Form 108 Insurer's Complaint for Modification, Discontinuance or Recoupment of Compensation - Massachusetts PDF

Form 108 Insurer's Complaint for Modification, Discontinuance or Recoupment of Compensation - Massachusetts
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Form 130 Complaint of Improper Claims Handling Against an Insurer - Massachusetts PDF

Form 130 Complaint of Improper Claims Handling Against an Insurer - Massachusetts
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Form 136 Affidavit of Indigence and Request for Waiver of 11a(2) Fees - Massachusetts PDF

Form 136 Affidavit of Indigence and Request for Waiver of 11a(2) Fees - Massachusetts
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Form 117 Lump Sum Settlement Agreement for Injuries on or After 11/1/1986 - Massachusetts PDF

Form 117 Lump Sum Settlement Agreement for Injuries on or After 11/1/1986 - Massachusetts
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Form 121 Appeal of Conference Proceeding - Massachusetts PDF

Form 121 Appeal of Conference Proceeding - Massachusetts
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Form 127 Average Weekly Wage Computation Schedule - Massachusetts PDF

Form 127 Average Weekly Wage Computation Schedule - Massachusetts
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Form 152 Amendment, Suspension, or Closure of Vocational Rehabilitation Plan - Massachusetts PDF

Form 152 Amendment, Suspension, or Closure of Vocational Rehabilitation Plan - Massachusetts
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Form 170 Affidavit of Employee in Application for Trust Fund Benefits - Massachusetts PDF

Form 170 Affidavit of Employee in Application for Trust Fund Benefits - Massachusetts
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Form 109 Notification of Withdrawal of Claim or Complaint - Massachusetts PDF

Form 109 Notification of Withdrawal of Claim or Complaint - Massachusetts
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Form 112 Appeal to Reviewing Board - Massachusetts PDF

Form 112 Appeal to Reviewing Board - Massachusetts
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Form 141 Last Best Offer at Conference - Massachusetts PDF

Form 141 Last Best Offer at Conference - Massachusetts
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Form 140 Conference Memorandum - Massachusetts PDF

Form 140 Conference Memorandum - Massachusetts
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Form 122 Request for Section 37 or 37a Proceeding - Massachusetts PDF

Form 122 Request for Section 37 or 37a Proceeding - Massachusetts
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Form 154 Verification of Massachusetts Workers' Compensation Coverage for Out-of-State Employers Operating in Massachusetts - Massachusetts PDF

Form 154 Verification of Massachusetts Workers' Compensation Coverage for Out-of-State Employers Operating in Massachusetts - Massachusetts
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Form 105 Agreement to Extend 180 Day Payment Without Prejudice Period - Massachusetts PDF

Form 105 Agreement to Extend 180 Day Payment Without Prejudice Period - Massachusetts
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Form 162 Insurer's Hearing Memorandum - Massachusetts PDF

Form 162 Insurer's Hearing Memorandum - Massachusetts
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Form 110 Employee's Claim - Massachusetts PDF

Form 110 Employee's Claim - Massachusetts
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Form 126 Employee's Earning Report - Massachusetts PDF

Form 126 Employee's Earning Report - Massachusetts
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Form 46A Request for 46a Conference Inconjunction With Lump Sum Under 48 - Massachusetts PDF

Form 46A Request for 46a Conference Inconjunction With Lump Sum Under 48 - Massachusetts
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Form 134 Health Care Provider Complaint Form - Massachusetts PDF

Form 134 Health Care Provider Complaint Form - Massachusetts
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Form 113 Agreement to Pay Compensation - Massachusetts PDF

Form 113 Agreement to Pay Compensation - Massachusetts
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Form 101 Employer's First Report of Injury or Fatality - Massachusetts PDF

Form 101 Employer's First Report of Injury or Fatality - Massachusetts
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Instructions for Form 110 Employee Claim - Massachusetts (Haitian Creole) PDF

Instructions for Form 110 Employee Claim - Massachusetts (Haitian Creole)
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Instructions for Form 110 Employee Claim - Massachusetts PDF

Instructions for Form 110 Employee Claim - Massachusetts
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Form 133A Complaint Against Utilization Review Agent - Massachusetts PDF

Form 133A Complaint Against Utilization Review Agent - Massachusetts
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