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Massachusetts Form Center

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		(46A) Request For §46a Conference In Conjunction With Lump Sum Under §48 - N/D
		(101) Employer First Report of Injury -- With Instructions - 5/09
		(103) Insurer's Notification Of Payment - 9/04
		(104) Insurer's Notification Of Denial - 8/01
		(105) Agreement To Extend 180 Day Payment-Without-Prejudice Period - 11/01
		(106) Insurer's Notification Of Termination or Modification Of Weekly Compensation During Payment-Without-Prejudice Period - 8/01
		(107) Insurer's Notification Of Acceptance, Resumption, Termination Or Modification Of Weekly Compensation - 8/01
		(108) Insurer's Complaint For Modification, Discontinuance Or Recoupment Of Compensation - 11/01
		(109) Notification Of Withdrawal Of Claim Or Complaint - 8/01
		(110) Employee Claim Form -- With Instructions - 5/09
		(112) Appeal To Reviewing Board - 8/01
		(112a) Affidavit In Support Of Request For Waiver Of Filing Fee Under § 11C - 8/01
		(113) Agreement To Pay Compensation - 4/09
		(114) Notice Of Change/Appearance of Counsel - 9/01
		(115) Third Party Claim/Notice Of Lien - 8/01
		(116) Request For Lump Sum Conference - 5/09
		(116a) Employer Consent To Lump Sum Agreement - 8/01
		(116b) Addendum To Lump Sum Agreement: Vocational Rehabilitation Status - 8/01
		(116c) Lien Disclosure Form - 8/01
		(117) Agreement for Redeeming Liability by Lump Sum - for injuries on or after Nov. 1, 1986 - 8/01
		(117a) Agreement for Redeeming Liability by Lump Sum - for injuries before Nov. 1, 1986 - 8/01
		(121) Appeal Of Conference Order - 8/01
		(121a) Agreement that no Impartial Physician Report is Required - 8/01
		(122) Request For §§ 37/37A Proceedings/Agreement Forms - 11/01
		(123) Agreement Under Section 37 Or 37a12 - 11/06
		(124a) Notification Of Arbitration Award - 8/01
		(125) Motion For Expedited Conference - 2/07
		(126) Employee Earning Report - 8/01
		(127) Average Weekly Wage Computation Schedule - 8/05
		(130) Complaint of Improper Claims Handling Against an Insurer - 8/01
		(131) Request For Speedy Conference Because Of Hardship - 8/01
		(132) Affidavit In Support of Employee's Request For Speedy Conference Because Of Hardship - 8/01
		(133a) Utilization Review (UR) Agent Complaint Form - 6/06
		(134) Health Care Provider Complaint Form - 7/01
		(136) Affidavit Of Indigence And Request For Waiver Of §11A (2) Fees - 8/01
		Temporary Conference Memorandum Cover Sheet - 8/01
		(141) Last Best Offer at Conference - 8/01
		(151) Individual Written Rehabilitation Program Form - 8/01
		(152) Amendment/Suspension Or Closure Of Vocational Rehabilitation Plan - 8/01
		(153) Affidavit of Exemption for Certain Corporate Officers - 10/02
		(160) Employee Biographical Data form - 8/01
		(161) Employee's Hearing Memorandum - 8/04
		(162) Insurer's Hearing Memorandum - 8/04
		(170) Affidavit of Employee in Application for Trust Fund Benefits - 11/02
		(aff builders) Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers - 4/07
		(aff general) Workers’ Compensation Insurance Affidavit: General Businesses - 5/07
		(cr28) Workers Compensation COLA Data Form - N/D
		(Ins cert) Process for Submitting Insurer Request Certification Form - N/D
		(Insurance-Inquiry) Insurance Inquiry Form - N/D
		(KORRequest) DIA File Request - 8/05
		(OEVRReferralForm) Referral For Mandatory Meetings Held Under G.L.C.152, § 30g - N/D
		(OEVRTravelVoucher) Mileage Voucher - N/D
		(POSTER) Notice To Employess Poster - N/D
		(VR CHART) Certified Vendor Quarterly Report For O.E.V.R - N/D
		(vr recert) Rehabilitation Provider Certification Form - N/D
		(Vr review) Case Review Form - N/D
		(vr tf forms) Section 30H-VR Encumbrance Form - N/D
		(vr voucher numbers) Payment Voucher Input Form - N/D

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