Form 101 "Employer's First Report of Injury or Fatality" - Massachusetts

What Is Form 101?

This is a legal form that was released by the Massachusetts Department of Industrial Accidents - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2010;
  • The latest edition provided by the Massachusetts Department of Industrial Accidents;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form 101 by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Industrial Accidents.

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Download Form 101 "Employer's First Report of Injury or Fatality" - Massachusetts

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FORM 101
The Commonwealth of Massachusetts
DIA USE ONLY
Department of Industrial Accidents – Department 101
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470
Print Form
http://www.mass.gov/dia
EMPLOYER’S FIRST REPORT OF INJURY
OR FATALITY
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.
3. Social Security Number*:
1. Employee’s Name (Last, First, MI):
2. Home Telephone Number:
4. Sex:
E
M
F
M
P
5. Home Address (No., Street, City, State & Zip Code):
5a. Native Language Code:
6. Marital Status:
7. No. of Dependents:
L
M
S
O
Other:________________
Y
8. Date of Hire (mm/dd/yyyy):
9. Date of Birth (mm/dd/yyyy):
10. Average Weekly Wage:
E
$
Estimated
Actual
E
11. Employer’s Name:
12. Federal Tax I.D. Number:
E
13. Employer’s Address (No., Street, City, State & Zip Code):
14. Employer’s Telephone Number:
M
P
L
15. Industry Code (See Reverse Side):
O
16. Workers’ Compensation Insurance Carrier and Tel. No.
:
17. W.C. Policy Number:
(NOT LOCAL AGENT/ADMINISTRATOR)
Y
E
R
19. Business Type :
Service
Wholesale
Mfg.
18. Self-Insured?
Yes
No
Retail
Other ________________________
If Yes, Self-Insurer Number:
20a. Insurer’s Case/Claim File No.:
20. DATE OF INJURY (mm/dd/yyyy):
22. Location of Injury if not on Employer’s Premises:
21. Was Employee Injured on Employer’s Premises?
Yes
No
I
N
23. FIRST day of Total or Partial Incapacity to Earn Wages
24. FIFTH day of Total or Partial Incapacity to Earn Wages
J
(mm/dd/yyyy):
(mm/dd/yyyy):
U
R
25. If Employee has Died, Date of Death (mm/dd/yyyy):
26. Source of Injury (Chemicals, Machinery, etc.):
Y
I
27. Briefly Describe How Injury/Exposure Occurred and Body Part(s) involved:
N
F
O
R
M
28. Person to Whom Injury was Reported (list position):
29. Date Reported (mm/dd/yyyy):
30. Date Reported as work related
A
(mm/dd/yyyy):
T
I
32. Witness(es) to Injury - Give Full Name(s), if none state as such:
31. Injury Code(s)
Body Part Code(s)
O
a.
to body part
a.
N
b.
to body part
b.
c.
to body part
c.
33. Has Employee Returned to Work?
Yes
No
34. Date Employee Returned to Work(mm/dd/yyyy):
35. Employee’s Regular Occupation:
36. Has Employee Returned to Regular Occupation:
Yes
No
37. PREPARER’S Name (SEE INSTRUCTIONS ON REVERSE SIDE):
38. PREPARER’S Title:
P
R
E
P
39
PREPARER’S Signature (SEE INSTRUCTIONS ON REVERSE SIDE
40. Date Prepared (mm/dd/yyyy):
40a. PREPARER’S e-mail address:
.
):
A
R
E
R
-
*Disclosure of Social Security Number is Voluntary. It will aid in the processing of your report.
Form 101
Revised 7/2010 - Reproduce as needed.
THIS FORM DOES NOT CONSTITUTE AN EMPLOYEE’S CLAIM FOR BENEFITS UNDER WORKERS’ COMPENSATION.
FORM 101
The Commonwealth of Massachusetts
DIA USE ONLY
Department of Industrial Accidents – Department 101
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470
Print Form
http://www.mass.gov/dia
EMPLOYER’S FIRST REPORT OF INJURY
OR FATALITY
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.
3. Social Security Number*:
1. Employee’s Name (Last, First, MI):
2. Home Telephone Number:
4. Sex:
E
M
F
M
P
5. Home Address (No., Street, City, State & Zip Code):
5a. Native Language Code:
6. Marital Status:
7. No. of Dependents:
L
M
S
O
Other:________________
Y
8. Date of Hire (mm/dd/yyyy):
9. Date of Birth (mm/dd/yyyy):
10. Average Weekly Wage:
E
$
Estimated
Actual
E
11. Employer’s Name:
12. Federal Tax I.D. Number:
E
13. Employer’s Address (No., Street, City, State & Zip Code):
14. Employer’s Telephone Number:
M
P
L
15. Industry Code (See Reverse Side):
O
16. Workers’ Compensation Insurance Carrier and Tel. No.
:
17. W.C. Policy Number:
(NOT LOCAL AGENT/ADMINISTRATOR)
Y
E
R
19. Business Type :
Service
Wholesale
Mfg.
18. Self-Insured?
Yes
No
Retail
Other ________________________
If Yes, Self-Insurer Number:
20a. Insurer’s Case/Claim File No.:
20. DATE OF INJURY (mm/dd/yyyy):
22. Location of Injury if not on Employer’s Premises:
21. Was Employee Injured on Employer’s Premises?
Yes
No
I
N
23. FIRST day of Total or Partial Incapacity to Earn Wages
24. FIFTH day of Total or Partial Incapacity to Earn Wages
J
(mm/dd/yyyy):
(mm/dd/yyyy):
U
R
25. If Employee has Died, Date of Death (mm/dd/yyyy):
26. Source of Injury (Chemicals, Machinery, etc.):
Y
I
27. Briefly Describe How Injury/Exposure Occurred and Body Part(s) involved:
N
F
O
R
M
28. Person to Whom Injury was Reported (list position):
29. Date Reported (mm/dd/yyyy):
30. Date Reported as work related
A
(mm/dd/yyyy):
T
I
32. Witness(es) to Injury - Give Full Name(s), if none state as such:
31. Injury Code(s)
Body Part Code(s)
O
a.
to body part
a.
N
b.
to body part
b.
c.
to body part
c.
33. Has Employee Returned to Work?
Yes
No
34. Date Employee Returned to Work(mm/dd/yyyy):
35. Employee’s Regular Occupation:
36. Has Employee Returned to Regular Occupation:
Yes
No
37. PREPARER’S Name (SEE INSTRUCTIONS ON REVERSE SIDE):
38. PREPARER’S Title:
P
R
E
P
39
PREPARER’S Signature (SEE INSTRUCTIONS ON REVERSE SIDE
40. Date Prepared (mm/dd/yyyy):
40a. PREPARER’S e-mail address:
.
):
A
R
E
R
-
*Disclosure of Social Security Number is Voluntary. It will aid in the processing of your report.
Form 101
Revised 7/2010 - Reproduce as needed.
THIS FORM DOES NOT CONSTITUTE AN EMPLOYEE’S CLAIM FOR BENEFITS UNDER WORKERS’ COMPENSATION.
EMPLOYER’S FIRST REPORT OF INJURY OR FATALITY
FILING INSTRUCTIONS
1. WHEN TO FILE: File this form within 7 calendar days, not including Sundays and legal holidays, of receipt of notice of any injury alleged to have arisen
out of and in the course of employment, which totally or partially incapacitates an employee for a period of 5 or more calendar days from earning wages.
This form is not an admission of liability, but must be filed even though the Employer may believe that the Employee is not injured, or that the Employee is
not entitled to benefits under M.G.L. Chapter 152.
2. WHERE TO FILE: This form should be mailed to the Department of Industrial Accidents at the address shown on the front of the form. Copies must also be
provided to the Employee and to the Employer’s Workers’ Compensation insurer.
3. PENALTIES: Failure to report injuries on this form may result in a fine of $100.00 in accordance with M.G.L. Chapter 152, Section 6.
4. EMPLOYER’S NAME & SIGNATURE IN BOXES 37 & 39: This form must be filed by the employer or an authorized agent/representative of the
employer.
NATIVE LANGUAGE CODES
1 – English / 2 – Portuguese / 3 – Haitian Creole / 4 – Spanish / 5 – Chinese / 6 – Vietnamese / 7 – Cape Verdean / 9 – Other
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 Enucleation
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
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