FORM 106 The Commonwealth of Massachusetts Department of Industrial Accidents ­ Department 106 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 Info. Line 800-323-3249 ext. 7470 in Mass. Outside Mass. - 617-727-4900 ext. 7470 http://www.mass.gov/dia DIA Board # (If Known): INSURER'S NOTIFICATION OF TERMINATION OR MODIFICATION OF WEEKLY COMPENSATION DURING PAYMENT WITHOUT PREJUDICE PERIOD CHECK ONE BOX: TERMINATION MODIFICATION FILE ONLY WHEN PAYMENT HAS BEEN MADE WITHIN 14 DAYS. AT LEAST 7 DAYS WRITTEN NOTICE MUST BE GIVEN TO EMPLOYEE OF THE INTENT TO STOP PAYMENTS, UNLESS BASED ON ACTUAL INCOME OF EMPLOYEE 1. Insurance Carrier's Name and Address: 2. Self-insured?: Yes No If Yes Please Give Self-insurer Number: 4. Telephone Number of Insurer's Attorney: I N S U R E R 3. Name & Address of Insurer's Attorney: 5. Claim Representative's Name: 7. Insurer's Case File Number: 6. Claim Representative's Tel. Number & Ext.: 8. Did Insurer Receive First Report of Injury (Form 101); Yes No - If Yes - Date Received (mm/dd/yyyy): 10. Employee's Social Security Number*: 12. Date of Birth (mm/dd/yyyy): 13. Date of Injury (mm/dd/yyyy): 9. Employee's Name (Last, First, MI): 11. Employee's Address (No. and Street, City, State, Zip Code): E M P L O Y E E 14. First Day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy): 15. Fifth Day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy): 16. Employer's Name & Address (No. and Street, City, State, Zip Code): 17. Employer's Federal Tax ID #: 18. Employee Returned to Work: Yes If Yes - Date of Return (mm/dd/yyyy): No (If Yes - 7 days written notice not required) Employee's Income $________________ 19. Specify grounds for termination and give a brief statement of the specific facts supporting the grounds for termination. Failure to do so may cause loss of defenses under M.G.L. c 152, Sections 7(1) and 7(2). A. No Personal Injury _____________________________________________________________________________________________________ B. C. D. G. G R O U N D S X. Y. No Injury Arising Out of and in the Course of Employment _____________________________________________________________________ No Disability __________________________________________________________________________________________________________ No Causal Relationship Between Personal Injury and Disability _________________________________________________________________ Lack of Jurisdiction ____________________________________________________________________________________________________ Lack of Notice ________________________________________________________________________________________________________ Late Claim ___________________________________________________________________________________________________________ H. Other (Specify) ________________________________________________________________________________________________________ Use additional space on back of form if needed. 20. Last Date Through Which Payment Will Be Made (mm/dd/yyyy): 21. Date of Notification of Termination or Modification to the Employee (mm/dd/yyyy): 22. If this is a Modification rather than a Termination, please state the grounds and factual basis for the Modification and the prior rate(s) of weekly compensation paid and the Modification rate(s) of weekly compensation. Basis for Modification (use reverse side if needed). Prior Rate(s): Modified Rate(s): 23. Insurer's Signature: $_____________________ $_____________________ $_____________________ $_____________________ 24. Date Prepared (mm/dd/yyyy): *Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents. Please Print Clearly or Type. Unreadable forms will be returned. Form 106 - Revised 7/2013- Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com Explanation of Box 19 or Box 22 continued: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com