| Title |
Last Updated |
| Utilization Review Application (To Become An Approved Agent And Affidavit Of Compliance) |
August 23, 2019 |
| Statement Of Eligibility To Serve On Roster Of Impartial Physicians |
August 23, 2019 |
| Insurer Request Certification |
August 23, 2019 |
| Affidavit (General Business) |
August 23, 2019 |
| Utilization Review Agent Complaint Form |
August 22, 2019 |
| Third Party Claim Notice Of Lien |
August 22, 2019 |
| Request For Speedy Conference Because Of Hardship |
August 22, 2019 |
| Request For Section 46a Conference With Lump Sum Under Section 48 |
August 22, 2019 |
| Request For Section 37 Or 37A Proceeding |
August 22, 2019 |
| Request For Lump Sum Conference |
August 22, 2019 |
| Notification Of Arbitration Award |
August 22, 2019 |
| Notice Of Change Appearance Of Counsel |
August 22, 2019 |
| Motion For Expedited Conference |
August 22, 2019 |
| Lien Disclosure Form |
August 22, 2019 |
| Last Best Offer At Conference |
August 22, 2019 |
| Insurers Notification Of Payment |
August 22, 2019 |
| Insurers Hearing Memorandum |
August 22, 2019 |
| Individual Written Rehabilitation Program |
August 22, 2019 |
| Health Care Provider Complaint Form |
August 22, 2019 |
| Employees Hearing Memorandum |
August 22, 2019 |
| Employees Earning Report |
August 22, 2019 |
| Employees Claim With Filing Instructions |
August 22, 2019 |
| Employee Biographical Data |
August 22, 2019 |
| Consent Of Employer To Lump Sum Settlement |
August 22, 2019 |
| Complaint Of Improper Claims Handling Against Insurer |
August 22, 2019 |
| Average Weekly Wage Computation Schedule |
August 22, 2019 |
| Verification Of Massachusetts Workers Compensation Coverage For Out-Of-State Employers |
August 22, 2019 |
| Conference Memorandum Cover Sheet |
August 22, 2019 |
| Appeal Of Conference Proceeding |
August 22, 2019 |
| Amendment-Suspension-Closure Of Vocational Rehabilitation Plan |
August 22, 2019 |
| Agreement Under Section 37 Or 37A |
August 22, 2019 |
| Agreement That No Impartial Physician Report Is Required |
August 22, 2019 |
| Agreement For Redeeming Liability By Lump Sum - For Injuries Before 11-1-86 |
August 22, 2019 |
| Affidavit Of Indigence And Request For Waiver Of Section 11A(2) Fees |
August 22, 2019 |
| Affidavit Of Exemption For Certain Corporate Officers Or Directors |
August 22, 2019 |
| Affidavit Of Employee In Application For Trust Fund Benefits |
August 22, 2019 |
| Addendum To Lump Sum Settlement Agreement |
August 22, 2019 |
| Affidavit In Support Of Employees Request For Speedy Conference Because Of Hardship |
August 22, 2019 |
| Agreement To Pay Compensation |
December 20, 2018 |
| Mileage Voucher |
February 16, 2018 |
| MGL Sec. 65B Appeal Of Cancellation Or Termination Of Policy |
February 16, 2018 |
| Agreement To Extend 180 Day Payment Without Prejudice Period |
April 17, 2017 |
| Insurance Inquiry Form |
July 21, 2015 |
| Application For Employment Agency License Or Placement Agency Registration |
May 6, 2015 |
| Affidavit (Builders-Contractors-Electricians-Plumbers) |
May 6, 2015 |
| Notification Of Withdrawal Of Claim Or Complaint |
April 13, 2015 |
| Insurers Notification Of Termination Or Modification Of Weekly Compensation During Payment Without Prejudice Period |
April 13, 2015 |
| Insurers Notification Of Acceptance Resumption Termination Or Modification Of Weekly Compensation |
April 13, 2015 |
| Affidavit In Support Of Request For Waiver In Filing Fee Under s11C |
April 13, 2015 |
| Workers Compensation Insurance Affidavit - General Businesses |
April 13, 2015 |
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