E M P L O Y E E The Commonwealth of Massachusetts Department of Industrial Accidents 226 Department 103 Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111-1750 Info. Line: (857) 321-7470 (Outside Mass.) / (800) 323-3249 (Inside Mass.) ) www.mass.gov/dia INSURER222S NOTIFICATION OF PAYMENT FILE THIS FORM WHEN WEEKLY BENEFITS ARE PAID WITHIN 14 DAYS OF INSURER222S RECEIPT OF A FIRST REPORT OF INJURY (FORM 101) OR AN INITIAL WRITTEN CLAIM FOR WEEKLY BENEFITS. DO NOT FILE THIS FORM FOR MEDICAL ONLY CLAIMS IMPORTANT - INSTRUCTIONS AND CODES ON THE REVERSE SIDE- Please Print Legibly or Type - Unreadable forms will be returned. DIA Board # (If Known): FORM 103 Form 103 - Revised 7/2019 - Reproduce as needed. 1. Insurance Carrier222s Name and Address: 4. Claim Representative222s Name: 6. Insurer222s Case File Number: 8. Did Insurer Receive a Written Claim for Benefits from the Employee?: Yes No If Yes - Date Received (mm/dd/yyyy): 9. Employee222s Name (Last, First, MI): 15. DATE OF INJURY (mm/dd/yyyy): 13. Employer222s Name: 17. FIRST day of total or Partial Incapacity to Earn Wages (mm/dd/yyyy): INSURER 2. Self-insured?: Yes No 3. Self-insurer Number: I N J U R Y 14. Employer222s Address (No. and Street, City, State, Zip Code): 16. Injury Code(s) a. to body part b. to body part c. to body part Body Part Code(s) a. b. c. 19. If Employee has Died Date of Death: 22. Insurer222s Signature : *Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents. 7. Did Insurer Receive First Report of Injury (Form 101): Yes No If Yes - Date Received (mm/dd/yyyy): 21. ACCEPTED PAID WITHOUT PREJUDICE Average Weekly Wage $ Estimated Actual (See M.G.L. Chapter 152, Section 1(1) for definition.) Date Insurer Mailed First Payment (mm/dd/yyyy): Amount Paid to Date: $ Paid Through (mm/dd/yyyy): Type of Weekly Compensation Weekly Compensation Paid a. Total, Temporary Incapacity - Section 34 $ b. Permanent & Total Incapacity - Section 34A $ c. Partial Incapacity - Section 35 $ d. Dependency Coverage - Section 35A $ e. Survivor222s Benefits - Section 31 $ C O M P E N S A T I O N 5. Claim Representative222s Tel. Number & Ext. : 10. Employee222s Social Security Number*: 11. Employee222s Address (No. and Street, City, State, Zip Code): 12. Date of Birth (mm/dd/yyyy): 18. FIFTH day of total or Partial Incapacity to Earn Wages (mm/dd/yyyy): 20. Description (left leg...lower back205etc.): 23. Date Prepared (mm/dd/yyyy): American LegalNet, Inc. www.FormsWorkFlow.com INSURER222S NOTIFICATION OF PAYMENT FILING INSTRUCTIONS 1. WHEN TO FILE: File this form within 14 days of the Insurer222s receipt of the Employer222s First Report of Injury (Form 101) or a written claim for weekly benefits on a form prescribed by the Department (Form 110) pursuant to 452 CMR 1.05(1). 2. WHERE TO FILE: This form should be mailed to the DIA at the address shown on the front of the form with a copy to the Employee and to the Employer. Agriculture, Forestry and Fishing 01 Agriculture Production - Crops 02 Agriculture Production - Livestock 07 Agricultural Services 08 Forestry 09 Fishing, Hunting and Trapping Mining 10 Metal Mining 12 Coal Mining 13 Oil and Natural Gas 14 Nonmetallic Minerals, Except Fuels Construction 15 General Building Contractors 16 Heavy Construction, Ex. Building 17 Special Trade Contractors Manufacturing 20 Food and Kindred Products 21 Tobacco Products 22 Textile Mill Products 23 Apparel and Other Textile Products 24 Lumber and Wood Products 25 Furniture and Fixtures 26 Paper and Allied Products 27 Printing and Publishing 28 Chemicals and Allied Products 29 Petroleum and Coal Products 30 Rubber and Misc. Plastic Products 31 Leather and Leather Products 32 Stone, Clay and Glass Products 33 Primary Metal Industries 34 Fabricated Metal Products 35 Industrial Machinery and Equipment 36 Electronic and Other Electrical Equipment 37 Transportation Equipment 38 Instruments and Related Products 39 Miscellaneous Manufacturing Industries Transportation and Public Utilities 40 Railroad Transportation 41 Local and Interurban Passenger Transit 42 Trucking and Warehousing 43 U.S. Postal Service 44 Water Transportation 45 Transportation by Air 46 Pipelines, Except Natural Gas 47 Transportation Services 48 Communications 49 Electric, Gas and Sanitary Services Wholesale Trade 50 Wholesale Trade - Durable Goods 51 Wholesale Trade - Non-durable Goods Retail Trade 52 Building Materials and Garden Supplies 53 General Merchandizing 54 Food Stores 55 Automotive Dealers and Service Stations 56 Apparel and Accessory Stores 57 Furniture and Home Furnishing Stores 58 Eating and Drinking Establishments 59 Miscellaneous Retail Finance, Insurance and Real Estate 60 Depository Institutions 61 Non-depository Institutions 62 Security and Commodity Brokers 63 Insurance Carriers 64 Insurance Agents, Brokers and Service 65 Real Estate 67 Holding and Other Investment Officers Services 70 Hotels and Other Lodging Places 72 Personal Services 73 Business Services 75 Auto Repair Services and Parking 76 Miscellaneous Repair Services 78 Motion Pictures 79 Amusements and Recreation Services 80 Health Services 81 Legal Services 82 Educational Services 83 Social Services 84 Museums, Botanical, Zoological Gardens 86 Membership Organizations 87 Engineering and Management Services 88 Private Households 89 Services, NEC Public Administration 91 Executive, Legislative and Garden 92 Justice, Public Order, and Safety 93 Finance, Taxation, and Monetary Benefits 94 Administration of Human Services 95 Environmental Quality and Housing 96 Administration of Economic Program 97 National Security and International Affairs Non-classifiable Establishments 99 Non-classifiable Establishments NATURE OF INJURY OR ILLNESS CODES 100 Amputation or Enucleation 110 Asphyxia or Strangulation Etc. 120 Burns (Heat) 130 Burns (Chemical) 140 Concussion 160 Contusion, Crushing, Bruise 170 Cut, Laceration, Puncture 190 Dislocation 200 Electric Shock, Electrocution 210 Fracture 250 Hernia, Rupture 300 Scratches, Abrasions 310 Sprains, Strains 400 Multiple Injuries 900 No Injury 950 Damage to Prosthetic Devices 995 No Other Injury, NEC** 999 Non-classifiable Infective or Parasitic Disease 150 Infective or Parasitic Disease, UNS* 151 Amebiasis 152 Anthrax 153 Brucellosis 154 Conjunctivitis and Opthalmia 156 Tetanus BODY PART AFFECTED CODES 157 Tuberculosis 159 Other Infective or Parasitic Diseases Dermatitis 180 Dermatitis, UNS* 183 Primary Infections of the Skin 184 Other Skin Conditions 185 Dermatitis, Allergenic or Contact 189 Skin Condition, NEC** Poisoning Systemic 270 Poisoning, Systemic, UNS* 271 Due to Toxic Materials other than Lead 272 Diseases of the Blood and Blood Forming Organs 273 Upper Respiratory Conditions 274 Influenza, Pneumonia, Etc. 276 Other Diseases of the Gastro-Intestinal Tract 278 Effects of Lead 279 Other Toxic Effects of One System Only Respiratory Systems, Conditions of 570 Respiratory Systems, Conditions of 571 Upper Respiratory 572 Asthma, Influenza, Pneumonia Pneumoconiosis 280 Pneumoconiosis 281 Aluminosis 282 Anthracosis 283 Asbestosis 284 Byssinosis 285 Siderosis 286 Silicosis 287 Other Pneumoconioses 289 Pneumoconiosis and Tuberculosis Nervous System, Conditions of 560 Nervous System, Conditions of - NEC** 561 Diseases of the Central Nervous System 562 Diseases of the Nerves and Peripheral Ganglia Neoplasm Tumor 550 Neoplasm Tumor, UNS* 551 Malignant 552 Benign Radiation Effects 290 Radiation Effects, UNS* 291 Non-Ionizing Radiation 292 Microwaves 293 Ionizing Radiation - X-Ray 294 Ionizing Radiation - Isotopes 295 Welder222s Flash Other 265 Carpal Tunnel Syndrome 510 Cardiovascular and Other Conditions of the Circulatory System 520 Complications Peculiar to Medical Care 500 Effects of Changes in Atmospheric Pressure 240 Effects of Environmental Heat 220 Effects of Exposure to Low Temperature 530 Eye, other Diseases of the Eye 230 Hearing Loss or Impairment 991 Heart Condition ,Excludes Heart Attack 320 Hemorrhoids 330 Hepatitis, Serum and Infective 275 Hepatitis, Toxic 260 Inflammation of Joints, Etc. 540 Mental Disorders 900 No Illness 999 Non-classifiable 990 Occupational Dis