Massachusetts > Workers Comp
Agreement To Extend 180 Day Payment Without Prejudice Period 105 - Massachusetts
| Agreement To Extend 180 Day Payment Without Prejudice Period Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 105 The Commonwealth of Massachusetts Department of Industrial Accidents Department 105 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 http://www.mass.gov/dia DIA Board # (If Known): AGREEMENT TO EXTEND 180 DAY PAYMENT WITHOUT PREJUDICE PERIOD FILE THIS FORM ONLY IF THE INSURER HAS PAID WEEKLY BENEFITS WITHIN 14 DAYS OF THE RECEIPT OF THE EMPLOYER'S FIRST REPORT OF INJURY (FORM 101) OR A CLAIM FOR WEEKLY BENEFITS (FORM 110) Please Print Legibly or Type - Unreadable forms will be returned. 1. Insurance Carrier's Name and Address: I N S U R E R 2. Self-insured?: Yes No If Yes Please Give Self-insurer Number: 3. Claims Representative's Name: 4. Claims Representative's Tel. Number & Ext. : 5. Insurer's Case File Number: 6. Did Insurer Receive First Report of Injury (Form 101): Yes No - If Yes - Date Received (mm/dd/yyyy) 7. Employee's Name (Last, First, MI): E M P L O Y E E 8. Employee's Social Security Number*: 9. Employee's Address (No. and Street, City, State, Zip Code): 10. Date of Birth (mm/dd/yyyy): 11. Employer's Name : 12. Date of Injury (mm/dd/yyyy): 13. First Day of Total or Partial Incapacity to Earn Wages: C O M P. 14. Fifth Day of Total or Partial Incapacity to Earn Wages: 15. Has Insurer Made All Payments Since the First Date of Total or Partial Incapacity to Earn Wages?: Yes No 16. Last Day Payment Can Be Made Pursuant to This Extension - NOT TO EXCEED 1 YEAR from 1st day of incapacity per c. 152 Sec. 8(6) - (mm/dd/yyyy): 17. Preparer for Insurer (Please Print or Type): 18. Insurer's Signature ("On-File" is NOT acceptable. Must have signature.): S I G N A T U R E S 19. Date (mm/dd/yyyy): 20. Name and Address of Employee's Attorney: 21. Signature of Employee's Attorney: 22. Date (mm/dd/yyyy): 23. Employee's Signature: 24. Date (mm/dd/yyyy): THIS AGREEMENT APPROVED AS NOT DETRIMENTAL TO THE EMPLOYEE'S CASE 25. Signature of Judge or Conciliator: 26. Date (mm/dd/yyyy): Form 105 *Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents. - Revised 7/2010 - Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com
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