Form 113 Agreement to Pay Compensation - Massachusetts

Form 113 or the "Agreement To Pay Compensation" is a form issued by the Massachusetts Department of Industrial Accidents.

The form was last revised in May 1, 2018 and is available for digital filing. Download an up-to-date Form 113 in PDF-format down below or look it up on the Massachusetts Department of Industrial Accidents Forms website.

ADVERTISEMENT
FORM 113
The Commonwealth of Massachusetts
DIA Board #
(if known)
Department of Industrial Accidents – Department 113
1 Congress Street, Suite 100, 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
AGREEMENT TO PAY COMPENSATION
This form should be used only for cases in which liability has been accepted. Codes and instructions on the reverse side.
1. Employee’s Name (Last, First, MI):
2. Date of Birth (mm/dd/yyyy):
3. Social Security Number*:
4. Home Address (No., Street, City, State & Zip Code)
5. Employer’s Name and Address (No., Street, City, State & Zip Code) :
6. Insurer’s Name & Address (No, Street, City, State & Zip Code) :
7B. Claim Rep. Tel. #:
8. Insurer’s File Number:
7A. Claim Rep. Name:
9. DATE OF INJURY (mm/dd/yyyy):
10. If Employee has Died, Date of Death (mm/dd/yyyy):
12. FIFTH day of Total or Partial Incapacity to Earn Wages
11. FIRST day of Total or Partial Incapacity to Earn Wages
(mm/dd/yyyy):
(mm/dd/yyyy):
13. Briefly Describe How Injury/Exposure Occurred and Body Part(s) involved:
14. Injury Code(s)
Body Part Code(s)
a.
to body part
a.
b.
to body part
b.
c.
to body part
c.
$_____________________
Estimated
Actual
15. Average Weekly Wage:
16. Does this agreement close out the current litigation? Yes
No
Not Applicable
If the answer is no, what issues remain in dispute?
________________________________________________________________________________________________________
THE PARTIES AGREE TO COMPENSATION IN ACCORDANCE TO THE FOLLOWING SCHEDULE:
17.
Type of Compensation
Amount Paid to Date or
Agreement Period
Weekly Comp.
One-time Comp. Amount
From Date
To Date
Amount
A.
Survivor’s Benefits
(§ 31)
$________________________
$_______________________
B.
Burial Expenses
(§ 33)
$________________________
$_______________________
C.
Temporary, Total Incapacity
(§ 34)
$________________________
$_______________________
D.
Permanent & Total Incapacity (§ 34A)
$________________________
$_______________________
E.
Partial Incapacity
(§ 35)
$________________________
$_______________________
F.
Dependency Coverage
(§ 35A)
$________________________
$_______________________
§
G. SPECIFIC PERMANENT INJURIES/ §36. Please set out the subsection under M.G.L. c. 152
36 and the amount of payment.
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
H. Other (specify) ____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
18. Employee/Claimant Signature:
19. Date (mm/dd/yyyy):
20
Employee Counsel Signature
21. Date (mm/dd/yyyy):
.
:
22
Insurer Counsel /Claim Rep Signature:
23. Date (mm/dd/yyyy):
.
APPROVAL FOR THE DEPARTMENT BY:
NAME: ___________________________________ TITLE: _____________________________ DATE:_________________
113 -
*Disclosure of social security number is voluntary. It will aid in the processing of your claim.
Form
Revised 5/2018- Reproduce as needed.
FORM 113
The Commonwealth of Massachusetts
DIA Board #
(if known)
Department of Industrial Accidents – Department 113
1 Congress Street, Suite 100, 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
AGREEMENT TO PAY COMPENSATION
This form should be used only for cases in which liability has been accepted. Codes and instructions on the reverse side.
1. Employee’s Name (Last, First, MI):
2. Date of Birth (mm/dd/yyyy):
3. Social Security Number*:
4. Home Address (No., Street, City, State & Zip Code)
5. Employer’s Name and Address (No., Street, City, State & Zip Code) :
6. Insurer’s Name & Address (No, Street, City, State & Zip Code) :
7B. Claim Rep. Tel. #:
8. Insurer’s File Number:
7A. Claim Rep. Name:
9. DATE OF INJURY (mm/dd/yyyy):
10. If Employee has Died, Date of Death (mm/dd/yyyy):
12. FIFTH day of Total or Partial Incapacity to Earn Wages
11. FIRST day of Total or Partial Incapacity to Earn Wages
(mm/dd/yyyy):
(mm/dd/yyyy):
13. Briefly Describe How Injury/Exposure Occurred and Body Part(s) involved:
14. Injury Code(s)
Body Part Code(s)
a.
to body part
a.
b.
to body part
b.
c.
to body part
c.
$_____________________
Estimated
Actual
15. Average Weekly Wage:
16. Does this agreement close out the current litigation? Yes
No
Not Applicable
If the answer is no, what issues remain in dispute?
________________________________________________________________________________________________________
THE PARTIES AGREE TO COMPENSATION IN ACCORDANCE TO THE FOLLOWING SCHEDULE:
17.
Type of Compensation
Amount Paid to Date or
Agreement Period
Weekly Comp.
One-time Comp. Amount
From Date
To Date
Amount
A.
Survivor’s Benefits
(§ 31)
$________________________
$_______________________
B.
Burial Expenses
(§ 33)
$________________________
$_______________________
C.
Temporary, Total Incapacity
(§ 34)
$________________________
$_______________________
D.
Permanent & Total Incapacity (§ 34A)
$________________________
$_______________________
E.
Partial Incapacity
(§ 35)
$________________________
$_______________________
F.
Dependency Coverage
(§ 35A)
$________________________
$_______________________
§
G. SPECIFIC PERMANENT INJURIES/ §36. Please set out the subsection under M.G.L. c. 152
36 and the amount of payment.
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
H. Other (specify) ____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
18. Employee/Claimant Signature:
19. Date (mm/dd/yyyy):
20
Employee Counsel Signature
21. Date (mm/dd/yyyy):
.
:
22
Insurer Counsel /Claim Rep Signature:
23. Date (mm/dd/yyyy):
.
APPROVAL FOR THE DEPARTMENT BY:
NAME: ___________________________________ TITLE: _____________________________ DATE:_________________
113 -
*Disclosure of social security number is voluntary. It will aid in the processing of your claim.
Form
Revised 5/2018- Reproduce as needed.
AGREEMENT TO PAY COMPENSATION
FILING INSTRUCTIONS
PENALTIES UNDER M.G.L. c. 152 § 8(1) SHALL RESULT IF PAYMENT, PURSUANT
TO THIS AGREEMENT, IS NOT MADE WITHIN 14 DAYS OF THE INSURER’S RECEIPT OF THE
APPROVED DOCUMENT. THE ORIGINAL FORM MUST BE FILED WITH THE
DEPARTMENT AND WILL NOT BE RETURNED TO THE PARTIES.
INDUSTRY CODES
Agriculture, Forestry and Fishing
28 Chemicals and Allied Products
51 Wholesale Trade - Non-durable Goods
78 Motion Pictures
01 Agriculture Production - Crops
29 Petroleum and Coal Products
79 Amusements and Recreation Services
02 Agriculture Production - Livestock
30 Rubber and Misc. Plastic Products
Retail Trade
80 Health Services
07 Agricultural Services
31 Leather and Leather Products
52 Building Materials and Garden Supplies
81 Legal Services
08 Forestry
32 Stone, Clay and Glass Products
53 General Merchandizing
82 Educational Services
09 Fishing, Hunting and Trapping
33 Primary Metal Industries
54 Food Stores
83 Social Services
34 Fabricated Metal Products
55 Automotive Dealers and Service Stations
84 Museums, Botanical, Zoological Gardens
Mining
35 Industrial Machinery and Equipment
56 Apparel and Accessory Stores
86 Membership Organizations
10 Metal Mining
36 Electronic and Other Electrical Equipment
57 Furniture and Home Furnishing Stores
87 Engineering and Management Services
12 Coal Mining
37 Transportation Equipment
58 Eating and Drinking Establishments
88 Private Households
13 Oil and Natural Gas
38 Instruments and Related Products
59 Miscellaneous Retail
89 Services, NEC
14 Nonmetallic Minerals, Except Fuels
39 Miscellaneous Manufacturing Industries
Finance, Insurance and Real Estate
Public Administration
Construction
Transportation and Public Utilities
60 Depository Institutions
91 Executive, Legislative and Garden
15 General Building Contractors
40 Railroad Transportation
61 Non-depository Institutions
92 Justice, Public Order, and Safety
16 Heavy Construction, Ex. Building
41 Local and Interurban Passenger Transit
62 Security and Commodity Brokers
93 Finance, Taxation, and Monetary Benefits
17 Special Trade Contractors
42 Trucking and Warehousing
63 Insurance Carriers
94 Administration of Human Services
43 U.S. Postal Service
Manufacturing
64 Insurance Agents, Brokers and Service
95 Environmental Quality and Housing
44 Water Transportation
20 Food and Kindred Products
65 Real Estate
96 Administration of Economic Program
45 Transportation by Air
21 Tobacco Products
67 Holding and Other Investment Officers
97 National Security and International Affairs
46 Pipelines, Except Natural Gas
22 Textile Mill Products
47 Transportation Services
Services
23 Apparel and Other Textile Products
Non-classifiable Establishments
48 Communications
70 Hotels and Other Lodging Places
24 Lumber and Wood Products
99 Non-classifiable Establishments
49 Electric, Gas and Sanitary Services
72 Personal Services
25 Furniture and Fixtures
73 Business Services
26 Paper and Allied Products
Wholesale Trade
75 Auto Repair Services and Parking
27 Printing and Publishing
50 Wholesale Trade - Durable Goods
76 Miscellaneous Repair Services
NATURE OF INJURY OR ILLNESS CODES
100 Amputation or Erucloation
157 Tuberculosis
281 Aluminosis
Other
110 Asphyxia or Strangulation Etc.
159 Other Infective or Parasitic Diseases
282 Anthracosis
265 Carpal Tunnel Syndrome
120 Burns (Heat)
Dermatitis
283 Asbestosis
510 Cardiovascular and Other Conditions
130 Burns (Chemical)
180 Dermatitis, UNS*
284 Byssinosis
of the Circulatory System
140 Concussion
183 Primary Infections of the Skin
285 Siderosis
520 Complications Peculiar to Medical Care
160 Contusion, Crushing, Bruise
184 Other Skin Conditions
286 Silicosis
500 Effects of Changes in Atmospheric
170 Cut, Laceration, Puncture
185 Dermatitis, Allergenic or Contact
287 Other Pneumoconioses
Pressure
190 Dislocation
189 Skin Condition, NEC**
289 Pneumoconiosis and Tuberculosis
240 Effects of Environmental Heat
200 Electric Shock, Electrocution
Poisoning Systemic
Nervous System, Conditions of
220 Effects of Exposure to Low Temperature
210 Fracture
270 Poisoning, Systemic, UNS*
560 Nervous System, Conditions of - NEC**
530 Eye, other Diseases of the Eye
250 Hernia, Rupture
271 Due to Toxic Materials other than Lead
561 Diseases of the Central Nervous
230 Hearing Loss or Impairment
300 Scratches, Abrasions
272 Diseases of the Blood and Blood Forming
System
991 Heart Condition ,Excludes Heart Attack
310 Sprains, Strains
Organs
562 Diseases of the Nerves and Peripheral
320 Hemorrhoids
400 Multiple Injuries
273 Upper Respiratory Conditions
Ganglia
330 Hepatitis, Serum and Infective
900 No Injury
274 Influenza, Pneumonia, Etc.
Neoplasm Tumor
275 Hepatitis, Toxic
950 Damage to Prosthetic Devices
276 Other Diseases of the Gastro-Intestinal
550 Neoplasm Tumor, UNS*
260 Inflammation of Joints, Etc.
995 No Other Injury, NEC**
Tract
551 Malignant
540 Mental Disorders
999 Non-classifiable
278 Effects of Lead
552 Benign
900 No Illness
Infective or Parasitic Disease
279 Other Toxic Effects of One System Only
Radiation Effects
999 Non-classifiable
150 Infective or Parasitic Disease, UNS*
Respiratory Systems, Conditions of
290 Radiation Effects, UNS*
990 Occupational Disease, NEC**
151 Amebiasis
570 Respiratory Systems, Conditions of
291 Non-Ionizing Radiation
580 Symptoms and Ill-defined Conditions
152 Anthrax
571 Upper Respiratory
292 Microwaves
153 Brucellosis
572 Asthma, Influenza, Pneumonia
293 Ionizing Radiation - X-Ray
154 Conjunctivitis and Opthalmia
Pneumoconiosis
294 Ionizing Radiation - Isotopes
156 Tetanus
280 Pneumoconiosis
295 Welder’s Flash
BODY PART AFFECTED CODES
Head
160 Skull
398 Upper Extremities, Multiple
513 Knee(s)
100 Head, UNS*
198 Head Multiple
400 Trunk, UNS*
515 Lower Leg(s)
110 Brain
200 Neck & Cervical Vertebrae
410 Abdomen, Internal Organs,
518 Leg(s), Multiple
120 Ear(s), UNS*
UPPER EXTREMITIES
Inguinal Hernia
519 Leg(s), NEC**
121 Ear(s), External
300 Upper Extremities, NEC**
420 Back
520 Ankle(s)
124 Ear(s), Internal
310 Arm(s), UNS*
430 Chest, Ribs, Breastbone,
530 Foot or Feet, Not Ankle
130 Eye(s), UNS*
311 Upper Arm
Internal Organs
540 Toe(s)
140 Face, UNS*
313 Elbow(s)
440 Hip(s)..,Pelvis, Organs and
598 Lower Extremities, Multiple
141 Jaw, Chin
315 Forearm(s)
Buttocks
700 MULTIPLE PARTS
144 Mouth and Throat (vocal chords, larynx)
318 Arm(s), Multiple
450 Shoulder(s)
Applies when more than one major body part
146 Nose
319 Arm(s), NEC**
498 Trunk, Multiple
as been effected such as an arm and a leg
148 Face, Multiple Parts
320 Wrist(s)
LOWER EXTREMITIES
999 NON-CLASSIFIABLE - Insufficient infor-
149 Face, NEC**
330 Hand(s), Not Wrists or Fingers
500 Lower Extremities
mation to identify part of body effected. In-
150 Scalp
340 Finger(s)
510 Leg(s), UNS*
cludes damage to prosthetic devises.
*UNS - UNSPECIFIED
**NEC - NOT ELSEWHERE CLASSIFIED

Download Form 113 Agreement to Pay Compensation - Massachusetts

798 times
Rate
4.8(4.8 / 5) 56 votes
ADVERTISEMENT
Page of 2