Employees Earning Report {126}

DIA USE ONLY *Disclosure of Social Security Number is Voluntary. It will assist in the processing of your report. Reproduce as needed. Form 126 - Revised 7/2019 2. Social Security Number*: 8. Date of Birth (mm/dd/yy): 7. DIA Board Number (If Known): As an employee entitled to receive weekly compensation, you have an affirmative duty to report to the insurer all earnings, including wages or salary from self - employment . If you fail to report any earnings whether paid cash or otherwise, you may be subject to civil or criminal penalties . If you fail to return this form within 30 days of this request, the insurer may suspend your weekly benefits under M . G . L . Chapter 152 247 11 D ( 1 ) . You cannot be required to file an earnings report more often than once every six months . Please report your earnings below : THE EMPLOYEE MUST MAIL THIS COMPLETED FORM TO THE INSURER AT THE ADDRESS INDICATED BELOW: 10. Name/ Address of Employer or other Payer of Wages, Commissions, Etc. If more than one payer, please list additional name s a nd addresses on back. 11. I have not received earnings for any period in which I was entitled to receive Workers' Compensation Benefits. Mark box with an X if the above statement is TRUE under the pains and penalties of perjury. 13. Date Signed (mm/dd/yyyy) 9 . Week No. Year: Week Ending Month Day Year: Week Ending Month Day Gross Amount Before Taxes Gross Amount Before Taxes 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Week No. The Commonwealth of Massachusetts Department of Industrial Accidents Department 126 Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111 - 1750 Info. Line (800) 323 - 3249 Inside Mass. / (857) 321 - 7470 Outside Mass. www.mass.gov/dia FORM 126 3. Date of Injury (mm/dd/yy): American LegalNet, Inc. www.FormsWorkFlow.com Names and Addresses of additional employers: American LegalNet, Inc. www.FormsWorkFlow.com