Employee Biographical Data {160}

EMPLOYEE BIOGRAPHICAL DATA Please Print or Type Form 160 - Revised 7/2019 - Reproduce as needed. 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. 3. Home Telephone No.: 5. Home Address (No., Street, City, State & Zip Code): 7. Place of Birth: 9. Marital Status: 4. Number of Dependents: 2. Social Security Number*: 6. Date of Birth: 8. Date U.S. Domicile Established: 10. Spouses Name: 11. Spouses Occupation: 12. Names and Ages of Children (attach additional sheet if needed): 1. Age 2. Age 3. Age 4. Age 5. Age 6. Age Education Employee 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: (OVER) Page 1 of 2 *Disclosure of Social Security No. is optional. It will aid in processing forms. FORM 160 The Commonwealth of Massachusetts Department of Industrial Accidents 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 American LegalNet, Inc. www.FormsWorkFlow.com 19. C. Employer: From - To Job Description: D. Employer: From - To Job Description: E. Employer: From - To Job Description: Work History - Continued 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. Date b. Date c. Date d. Date e. Date f. 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): Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com