Massachusetts > Workers Comp
Employee Biographical Data 160 - Massachusetts
| Employee Biographical Data Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 160 The Commonwealth of Massachusetts Department of Industrial Accidents 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 Page 1 of 2 EMPLOYEE BIOGRAPHICAL DATA PREPARE THIS FORM PRIOR TO A HEARING. THIS FORM IS TO BE GIVEN TO OPPOSING COUNSEL AND MAY BE OFFERED AS EVIDENCE IF SO TESTIFIED. Employee 1. Employee's Name (Last, First, MI): 5. Home Address (No., Street, City, State & Zip Code): Please Print or Type 2. Social Security Number*: 3. Home Telephone No.: 6. Date of Birth: 4. Number of Dependents: 7. Place of Birth: 9. Marital Status: 10. Spouses Name: 8. Date U.S. Domicile Established: 11. Spouses Occupation: 12. Names and Ages of Children (attach additional sheet if needed): 1. 3. 5. Age ______ Age_______ Age_______ 2. 4. 6. Age_______ Age_______ Age_______ Education 13. Name & Address of Last School Attended: 14. Highest Grade Completed and/or Date of Graduation: 15. List any Special Skills or Training Received: Military Service 16. Branch of Service and Rank: 17. Dates of Service (mm/dd/yyyy): 18. Military Occupation or Specialty: Work History (begin with most recent employment) 19. A. Employer: ____________________________________ From ______________ To _____________ Job Description: ____________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ B. Employer: ____________________________________ From ______________ To _____________ Job Description: ____________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ *Disclosure of Social Security No. is optional. It will aid in processing forms. (OVER) Form 160 - Revised 7/2010 - Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com Work History - Continued 19. Page 2 of 2 C. Employer: ____________________________________ From - ______________ To _____________ Job Description: ____________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ D. Employer: ____________________________________ From - ______________ To _____________ Job Description: ____________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ E. Employer: ____________________________________ From - ______________ To _____________ Job Description: ____________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Medical Data (related to industrial injury) 20. Date of First Medical Treatment (mm/dd/yyyy): 21. Place of First Medical Treatment: 22. Name(s) of Treating Physicians and Dates of Treatments (in Chronological Order): a. c. e. Date _____ Date _____ Date _____ b. d. f. Date _____ Date _____ Date _____ 23. Date(s) and Location(s) of OUTPATIENT Hospital Treatment: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 24. Date(s) and Location(s) of INPATIENT Hospital Treatment: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 25. List any Hospital Records and/or Physician reports to be Offered in Evidence by Agreement of Counsel (Please Attach): ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com
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