Massachusetts > Workers Comp
Agreement To Pay Compensation 113 - Massachusetts
| Agreement To Pay Compensation Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 113 The Commonwealth of Massachusetts Department of Industrial Accidents Department 113 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 PAY COMPENSATION This form should be used only for cases in which liability has been accepted. Codes and instructions on the reverse side. E M P L O Y E E 1. Employee's Name (Last, First, MI): 4. Home Address (No., Street, City, State & Zip Code) 5. Employer's Name & Address (No. , Street, City, State & Zip Code): 2. Date of Birth (mm/dd/yyyy): 3. Social Security Number*: 3a. No. of Dependents: 6. Self Insured: Yes If yes, Self-Insurer #: 7. Name of Workers' Compensation Insurance Carrier, Address and Tel. No. (NOT LOCAL AGENT/ADMINISTRATOR) No 8. Claim Representative's Name & Telephone Number: 9. Insurer's File Number: 10. DATE OF INJURY (mm/dd/yyyy): 12. FIRST day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy): 14. Briefly Describe How Injury/Exposure Occurred and Body Part(s) involved: 11. If Employee has Died, Date of Death (mm/dd/yy): 13. FIFTH day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy): 15. Injury Code(s) a. b. c. to body part to body part to body part Body Part Code(s) a. b. c. 16. Average Weekly Wage: $_____________________ Actual Estimated 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. B. C. D. E. F. Survivor's Benefits Burial Expenses Temporary, Total Incapacity Partial Incapacity Dependency Coverage (s.31) (s.33) (s.34) (s.35) $________________________ $________________________ $________________________ $________________________ $_______________________ $_______________________ $_______________________ $_______________________ $_______________________ $_______________________ Permanent & Total Incapacity (s.34A) $________________________ (s.35A) $________________________ G. SPECIFIC PERMANENT INJURIES/SECTION 36. Please set out the subsection under M.G.L. c. 152 §36 and the amount of payment. ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ H. Other (specify) ____________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ 18. Insurer's Representative's Signature and Title: 20. Name of Employee's Attorney: 21. Attorney's Signature (if applicable): 19. Date (mm/dd/yyyy): 22. Date (mm/dd/yyyy): 23. Employee's Signature (REQUIRED): 24. Date (mm/dd/yyyy): DIA USE ONLY- Do not write below. APPROVAL FOR THE DEPARTMENT BY: American LegalNet, Inc. www.FormsWorkFlow.com NAME: ___________________________________ TITLE: _____________________________ DATE:_________________ *Disclosure of Social Security Number is Voluntary. It will aid in the processing of your claim. Form 113 - Revised 7/2010 - Reproduce as needed. AGREEMENT TO PAY COMPENSATION FILING INSTRUCTIONS PENALTIES UNDER M.G.L. CH. 152 SECTION 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 01 Agriculture Production - Crops 02 Agriculture Production - Livestock 07 Agricultural Services 08 Forestry 09 Fishing, Hunting and Trapping Mining 10 Metal Mining 12 Coal Mining 13 Oil and Natural Gas 14 Nonmetallic Minerals, Except Fuels Construction 15 General Building Contractors 16 Heavy Construction, Ex. Building 17 Special Trade Contractors Manufacturing 20 Food and Kindred Products 21 Tobacco Products 22 Textile Mill Products 23 Apparel and Other Textile Products 24 Lumber and Wood Products 25 Furniture and Fixtures 26 Paper and Allied Products 27 Printing and Publishing 28 29 30 31 32 33 34 35 36 37 38 39 Chemicals and Allied Products Petroleum and Coal Products Rubber and Misc. Plastic Products Leather and Leather Products Stone, Clay and Glass Products Primary Metal Industries Fabricated Metal Products Industrial Machinery and Equipment Electronic and Other Electrical Equipment Transportation Equipment Instruments and Related Products Miscellaneous Manufacturing Industries 51 Wholesale Trade - Non-durable Goods Retail Trade 52 Building Materials and Garden Supplies 53 General Merchandizing 54 Food Stores 55 Automotive Dealers and Service Stations 56 Apparel and Accessory Stores 57 Furniture and Home Furnishing Stores 58 Eating and Drinking Establishments 59 Miscellaneous Retail Finance, Insurance and Real Estate 60 Depository Institutions 61 Non-depository Institutions 62 Security and Commodity Brokers 63 Insurance Carriers 64 Insurance Agents, Brokers and Service 65 Real Estate 67 Holding and Other Investment Officers Services 70 Hotels and Other Lodging Places 72 Personal Services 73 Business Services 75 Auto Repair Services and Parking 76 Miscellaneous Repair Services 78 79 80 81 82 83 84 86 87 88 89 Motion Pictures Amusements and Recreation Services Health Services Legal Services Educational Services Social Services Museums, Botanical, Zoological Gardens Membership Organizations Engineering and Management Services Private Households Services, NEC Transportation and Public Utilities 40 Railroad Transportation 41 Local and Interurban Passenger Transit 42 Trucking and Warehousing 43 U.S. Postal Service 44 Water Transportation 45 Transportation by Air 46 Pipelines, Except Natural Gas 47 Transportation Services 48 Communications 49 Electric, Gas and Sanitary Services Wholesale Trade 50 Wholesale Trade - Durable Goods Public Administration 91 Executive, Legislative and Garden 92 Justice, Public Order, and Safety 93 Finance, Taxation, and Monetary Benefits 94 Administration of Human Services 95 Environmental Quality and Housing 96 Administration of Economic Program 97 National Security and International Affairs Non-classifiable Establishmen
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