Blank Massachusetts 127 Form

The Massachusetts 127 form is an important document used for calculating average weekly wages for injured workers. Here are key takeaways regarding its completion and use:

• Accurate Information: Ensure all sections of the form are filled out accurately, including the employer's name, employee's details, and dates related to the injury and employment.
• Wage Reporting: Report only the wages earned by the injured worker during the 52 weeks prior to the injury. If the worker has been employed for less than 52 weeks, substitute wages from a fellow employee in the same role.
• Dependent Information: Include the number of dependent children and other dependents, as this information may impact the calculation of benefits.
• Certification of Disability: Indicate whether the employee has been certified by the U.S. Veterans Administration for any type of disability, as this may affect eligibility for certain benefits.
• Room and Board: Specify if room and board were provided to the employee, as this can influence the overall wage calculation.
• Tips and Other Benefits: If applicable, describe any tips or additional benefits earned by the employee, including their weekly value.
• Signature Requirement: The form must be signed by the employer or preparer, along with the date of signing, to validate the information provided.

Completing the Massachusetts 127 form correctly is essential for ensuring that injured workers receive the appropriate compensation based on their average weekly wage.

1. Incomplete Information: Failing to fill out all required fields, such as the employee's name or the date of injury, can lead to delays. Each section is crucial for processing your claim.

2. Incorrect Dates: Entering the wrong dates for injury or employment can cause confusion. Always double-check these entries to ensure accuracy.

3. Wrong Wage Reporting: Reporting wages that do not reflect the 52-week period before the injury can result in incorrect calculations. Only include wages earned during that specific timeframe.

4. Missing Dependent Information: Not providing the number of dependent children or other dependents may affect benefits. This information is important for determining eligibility.

5. Signature Errors: Forgetting to sign the form or having an unsigned preparer's section can lead to rejection. Ensure all necessary signatures are present before submission.

6. Failure to Describe Benefits: Not detailing any tips or additional benefits earned by the employee can lead to undervaluing their earnings. Be thorough in this section.

7. Neglecting Comments Section: Leaving the comments section blank can miss an opportunity to clarify any unusual circumstances. Use this space to provide any additional context that may be helpful.

When filling out the Massachusetts 127 form, it is essential to approach the process with care and attention to detail. Here are six important dos and don’ts to consider:

• Do print or type all information clearly to ensure legibility.
• Do include accurate dates for the injury, disability, and employment to avoid processing delays.
• Do report wages for the full 52-week period preceding the accident, or substitute wages from a fellow employee if necessary.
• Do ensure that the employer’s name and address are complete and correct.
• Don’t leave any sections blank; if a question does not apply, indicate that appropriately.
• Don’t forget to sign and date the form before submission to validate the information provided.

What is the purpose of the Massachusetts 127 form?

The Massachusetts 127 form is used to calculate the average weekly wage of an employee who has sustained a work-related injury. This form is essential for determining the appropriate compensation benefits for the injured worker. It collects information about the employee's earnings during the year prior to the injury, along with details about dependents and employment history.

Who needs to fill out the Massachusetts 127 form?

The employer or a designated preparer must complete the Massachusetts 127 form. It is necessary when an employee has been injured on the job and is seeking workers' compensation benefits. Accurate completion of the form is crucial for ensuring that the injured worker receives the correct benefits based on their average weekly wage.

What information is required on the Massachusetts 127 form?

The form requires various pieces of information, including the employer's name and address, the employee's name and address, the number of dependents, and specific dates related to the injury and employment. Additionally, it asks for the employee's wages over the 52 weeks preceding the injury. If the employee has worked for less than a year, wages from a comparable employee may be used.

How are wages reported on the Massachusetts 127 form?

Wages are reported by listing the gross amount earned before taxes for each week over the specified period. The form includes a schedule where the employer can enter weekly earnings. If the employee has not worked for the full 52 weeks, wages from a fellow employee in the same class of employment may be substituted for the missing weeks.

What should be done if the employee has received tips or other benefits?

If the employee has received tips or other benefits, the form requires a description of those benefits along with their estimated weekly value. This information is important for accurately calculating the average weekly wage and ensuring that all forms of compensation are considered in the benefits determination process.

Where can additional information about the Massachusetts 127 form be obtained?

Additional information regarding the Massachusetts 127 form can be obtained by contacting the Department of Industrial Accidents. The contact information is provided on the form itself. Individuals can reach out to the information line at 800-323-3249 ext. 7470 if they are in Massachusetts or at 617-727-4900 ext. 7470 for those outside the state. Further details can also be found on the Massachusetts government website.

Instructions on How to Fill Out Massachusetts 127

Completing the Massachusetts 127 form requires attention to detail and accuracy. This form is essential for reporting wages and other relevant information following an injury. After filling out the form, it will be submitted to the appropriate authorities for processing. Ensure that all information is correct to avoid delays.

1. Employer’s Name and Address: Enter the full name and address of the employer.
2. Insurer’s Case File #: Provide the case file number assigned by the insurer.
3. DIA Board # (if known): If applicable, include the DIA Board number.
4. Employee’s Name and Address: Fill in the injured employee’s full name and address.
5. # of dependent children: Indicate the number of dependent children the employee has.
6. # of other dependents: Specify any other dependents, if applicable.
7. Date of Injury (mm/dd/yyyy): Enter the date when the injury occurred.
8. Date of Disability (mm/dd/yyyy): Fill in the date when the employee became disabled.
9. Date of Employment (mm/dd/yyyy): Provide the date the employee began working for the employer.
10. Certification of Disability: Indicate whether the employee has been certified by the U.S. Veterans Administration for any type of disability by checking 'Yes' or 'No.'
11. Wage Reporting: Report the wages earned by the employee during the 52 weeks prior to the injury. If the employee has worked less than 52 weeks, use wages from a fellow employee in the same job class. Fill in the details for each week, including the week ending date and gross amount before taxes.
12. Room Furnished: Indicate if the employee was provided with furnished room accommodations by checking 'Yes' or 'No.'
13. Tips or Other Benefits: If applicable, describe any tips or benefits earned and state their value per week.
14. Name of Fellow Employee (if applicable): If using a fellow employee’s wages, provide their name.
15. Employer/Preparer Signature: The employer or preparer must sign the form.
16. Date Signed (mm/dd/yyyy): Enter the date the form was signed.

After completing the form, review all entries for accuracy. If additional comments or information are needed, include them on the reverse side of the form or on a separate sheet. Ensure that the form is submitted promptly to avoid delays in processing.