Form 126 "Employee's Earning Report" - Massachusetts

Form 126 or the "Employee's Earning Report" is a form issued by the Massachusetts Department of Industrial Accidents.

The form was last revised in July 1, 2013 and is available for digital filing. Download an up-to-date Form 126 in PDF-format down below or look it up on the Massachusetts Department of Industrial Accidents Forms website.

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Download Form 126 "Employee's Earning Report" - Massachusetts

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The Commonwealth of Massachusetts
DIA USE ONLY
FORM 126
Department of Industrial Accidents – Department 126
1 Congress Street, Suite100, Boston, Massachusetts 02114-2017
Info. Line 800 323-3249 ext. 7470 in Mass. Outside Mass. - 617-727-4900 ext. 7470
http://www.mass.gov/dia
EMPLOYEE’S EARNING REPORT
1. Employee’s Name (Last, First, MI):
2. Social Security Number*:
3. Date of Injury (mm/dd/yy):
4. Employee’s Mailing Address (No. & Street, City, State, Zip Code):
5. Employee’s Residential Address (if different from Mailing Address):
6. Employee’s Attorney (Last, First, MI) and Address (No. & Street, City, State, Zip Code):
7. DIA Board Number (If Known):
8. Date of Birth (mm/dd/yy):
As an employee entitled to receive weekly compensation, you have an affirmative duty to report to the insurer all earnings, including
wages or salary from self-employment. If you fail to report any earnings whether paid cash or otherwise, you may be subject to civil
or criminal penalties. If you fail to return this form within 30 days of this request, the insurer may suspend your weekly benefits
under M.G.L. Chapter 152 section 11D (1). You cannot be required to file an earnings report more often than once every six months.
Please report your earnings below:
Year:
Year:
9
.
Gross Amount
Gross Amount
Week
Week
Week Ending
Week Ending
Before Taxes
Before Taxes
No.
No.
Month
Day
Month
Day
1
14
2
15
3
16
4
17
5
18
6
19
7
20
8
21
9
22
10
23
11
24
12
25
13
26
10. Name/ Address of Employer or other Payer of Wages, Commissions, Etc. If more than one payer, please list additional names and
addresses on back.
11. I have not received earnings for any period in which I was entitled to receive Workers' Compensation Benefits.
Mark box with an X if the above statement is TRUE under the pains and penalties of perjury.
12. Employee’s Signature:
13. Date Signed (mm/dd/yyyy)
THE EMPLOYEE MUST MAIL THIS COMPLETED FORM TO THE INSURER AT THE ADDRESS INDICATED BELOW:
14. Insurance Carrier’s Name & Address (No. Street, City, State & Zip Code):
*Disclosure of Social Security Number is Voluntary. It will assist in the processing of your report.
Reproduce as needed.
Form 126 - Revised 7/2013
The Commonwealth of Massachusetts
DIA USE ONLY
FORM 126
Department of Industrial Accidents – Department 126
1 Congress Street, Suite100, Boston, Massachusetts 02114-2017
Info. Line 800 323-3249 ext. 7470 in Mass. Outside Mass. - 617-727-4900 ext. 7470
http://www.mass.gov/dia
EMPLOYEE’S EARNING REPORT
1. Employee’s Name (Last, First, MI):
2. Social Security Number*:
3. Date of Injury (mm/dd/yy):
4. Employee’s Mailing Address (No. & Street, City, State, Zip Code):
5. Employee’s Residential Address (if different from Mailing Address):
6. Employee’s Attorney (Last, First, MI) and Address (No. & Street, City, State, Zip Code):
7. DIA Board Number (If Known):
8. Date of Birth (mm/dd/yy):
As an employee entitled to receive weekly compensation, you have an affirmative duty to report to the insurer all earnings, including
wages or salary from self-employment. If you fail to report any earnings whether paid cash or otherwise, you may be subject to civil
or criminal penalties. If you fail to return this form within 30 days of this request, the insurer may suspend your weekly benefits
under M.G.L. Chapter 152 section 11D (1). You cannot be required to file an earnings report more often than once every six months.
Please report your earnings below:
Year:
Year:
9
.
Gross Amount
Gross Amount
Week
Week
Week Ending
Week Ending
Before Taxes
Before Taxes
No.
No.
Month
Day
Month
Day
1
14
2
15
3
16
4
17
5
18
6
19
7
20
8
21
9
22
10
23
11
24
12
25
13
26
10. Name/ Address of Employer or other Payer of Wages, Commissions, Etc. If more than one payer, please list additional names and
addresses on back.
11. I have not received earnings for any period in which I was entitled to receive Workers' Compensation Benefits.
Mark box with an X if the above statement is TRUE under the pains and penalties of perjury.
12. Employee’s Signature:
13. Date Signed (mm/dd/yyyy)
THE EMPLOYEE MUST MAIL THIS COMPLETED FORM TO THE INSURER AT THE ADDRESS INDICATED BELOW:
14. Insurance Carrier’s Name & Address (No. Street, City, State & Zip Code):
*Disclosure of Social Security Number is Voluntary. It will assist in the processing of your report.
Reproduce as needed.
Form 126 - Revised 7/2013
Names and Addresses of additional employers:
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