FORM 107 The Commonwealth of Massachusetts Department of Industrial Accidents ­ Department 107 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 ACCEPTANCE, RESUMPTION OR TERMINATION OR MODIFICATION OF WEEKLY COMPENSATION CHECK ONE BOX: ACCEPTANCE RESUMPTION TERMINATION MODIFICATION USE FORM 106 AS NOTICE TO TERMINATE OR MODIFY WEEKLY PAYMENTS BEING MADE WITHOUT PREJUDICE UNDER M.G.L., CHAPTER 152 §8(1). Please Print or Type. 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. Employee's Average Weekly Wage: $ 18. Employee Returned to Work: Yes If Yes - Date of Return (mm/dd/yyyy): No Actual Estimated 19. Date of Resumption, Modification or Termination (mm/dd/yyyy): 20. This is a Notice of Initial Acceptance of a Claim (ATTACH FORM 113). This is a Resumption/Modification of Payment of a Case Previously Accepted. This is a Resumption of Payment of a Case within the Payment Without Prejudice Period. This is a Resumption/Modification of Payment under §30G. Type of Compensation Resumed or Modified Former Weekly Compensation Rate Resumed or Modified Weekly Compensation Rate B E N E F I T S A. B. C. D. E. Temporary, Total Incapacity (§34) Permanent & Total Incapacity (§34A) Partial Incapacity (§35) Dependency Coverage (§35A) Survivor's Benefits (§31) $ $ $ $ $ $ $_________________ $_________________ $_________________ $ 21. If the Insurer is Terminating or Suspending Payment of Weekly Benefits without the Assent of the Employee or the Dept. of Industrial Accidents, set out the Applicable Statutory Section and Factual Basis Therefore (continue on the reverse side if needed): 22. If the Insurer is Terminating or Modifying with the Assent of the Compensation Recipient, the Recipient's Signature is Required. Signature of Recipient: 23. Insurer's Signature : 24. Date Prepared (mm/dd/yyyy): Form 107 - Revised 7/2013- Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com *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. Explanation of Box 21 continued: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com