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This form must be filed by the employer or an authorized agent/representative of the employer.
Step
1
of
3
0%
Employee Information
1a. Last Name
*
1b. First Name
*
1c. Middle Name/Initial
2. Home Telephone
*
3. Social Security Number
*
4a. Street Address
*
4b. City
*
4c. State
*
Massachusetts
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
4d. Zip Code
*
4e. Native Language
English
Portuguese
Haitian Creole
Spanish
Chinese
Vietnamese
Cape Verdean
Other
5. Marital Status
Single
Married
6. Number of Dependents
7. Date of Hire
*
MM slash DD slash YYYY
8. Date of Birth
*
MM slash DD slash YYYY
9. Sex
*
Male
Female
10a. Average Wage
Weekly
Bi-weekly
Monthly
Other
10b. Wage Amount
10c. Wage
Estimated
Actual
Employer Information
11. Employer's Name
*
12. Federal Tax ID Number
13a. Street Address
*
13b. City
*
13c. State
*
Massachusetts
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
13d. Zip Code
*
14. Employer Phone
*
15. Industry Code
01 Agriculture Production - Crops
02 Agriculture Production - Livestock
07 Agricultural Services
08 Forestry
09 Fishing, Hunting and Trapping
10 Metal Mining
12 Coal Mining
13 Oil and Natural Gas
14 Nonmetallic Minerals, Except Fuels
15 General Building Contractors
16 Heavy Construction, Ex. Building
17 Special Trade Contractors
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
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
50 Wholesale Trade - Durable Goods
51 Wholesale Trade - Non-durable Goods
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
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
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
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
99 Non-classifiable Establishments
16. Workers' Compensation Insurance Carrier Name and Telephone Number
Massachusetts Retail Merchants Workers’ Compensation Group, P.O. Box 859222-9222, Braintree, MA 02185, 1-800-790-8877
Massachusetts Care Self-Insurance Group, P.O. Box 859222-9222, Braintree, MA 02185, 1-800-790-8877
Massachusetts Healthcare Self-Insurance Group, P.O. Box 859222-9222, Braintree, MA 02185, 1-800-790-8877
Massachusetts Trade Self-Insurance Group, P.O. Box 859222-9222, Braintree, MA 02185, 1-800-790-8877
Massachusetts Manufacturing Self-Insurance Group, P.O. Box 859222-9222, Braintree, MA 02185, 1-800-790-8877
17. Workers' Compensation Policy Number
18a. Employer Self-Insured?
Yes
No
18b. If you answered YES, Self-lnsurer Number
19. Business Type
Service
Wholesale
Manufacturing
Retail
Other
Injury Information
20a. DATE OF INURY
*
MM slash DD slash YYYY
20b. Insurer's Case/Claim File Number
21. Was Employee Injured on Employer's Premises?
*
Yes
No
22. Location of lnjury
*
23. FIRST day of Total Partial Incapacity to Earn Wages
*
MM slash DD slash YYYY
24. FIFTH day of Total Partial Incapacity to Earn Wages
MM slash DD slash YYYY
25. If Employee has Died, Date of Death
MM slash DD slash YYYY
26. Source of Injury
(Chemicals, Machinery, etc.)
27. Briefly Describe How Injury/Exposure Occurred and Body Part(s) involved
*
28. Person to Whom Injury was Reported
*
(list name and position)
29. Date Reported
*
MM slash DD slash YYYY
30. Date Reported as work related
*
MM slash DD slash YYYY
31a. Nature of Injury(ies)
*
01 NO PHYSICAL INJURY
02 AMPUTATION
03 ANGINA PECTORIS (HEART)
04 BURN
07 CONCUSSION
10 CONTUSION
13 CRUSHING
16 DISLOCATION
19 ELECTRIC SHOCK
22 ENUCLEATION (REMOVE, EX TUMOR)
25 FOREIGN BODY
28 FRACTURE
30 FREEZING
31 HEARING LOSS OR IMPAIRMENT
32 HEAT PROSTRATION
34 HERNIA
36 INFECTION
37 INFLAMMATION
40 LACERATION
41 HEART ATTACK
42 POISONING-GENERAL
43 PUNCTURE
46 RUPTURE
47 SEVERANCE
49 SPRAIN
52 STRAIN
53 SYNCOPE (SWOONING, FAINTING)
54 ASPHYXIATION
55 VASCULAR LOSS
58 VISION LOSS
59 ALL OTHER INJURIES, NOC
60 DUST DISEASE NOC
61 ASBESTOSIS
62 BLACK LUNG DISEASE
63 BYSSINOSIS
64 SILICOSIS
65 RESPIRATORY DISORDER/GAS,FUMES
66 POISONING-CHEMICAL/NOT METALS
67 POISONING - METAL
68 DERMATITIS
69 MENTAL DISORDER
70 RADIATION
71 ALL OTHER OCC DISEASE
72 LOSS OF HEARING
73 CONTAGIOUS DISEASE
74 CANCER
75 AIDS
76 VDT-RELATED DISEASE
77 MENTAL STRESS
78 CARPAL TUNNEL SYNDROME
80 ALL OTHER CUMULATIVE INJ.,NOC
83 COVID-19
90 MULTIPLE PHYSICAL INJ ONLY
91 MULT INJ PHYS & PSYCHOLOGICAL
Multiple Selection / Type to Search
31b. Injured Body Part(s) Description
*
10 MULTIPLE HEAD INJURY
11 SKULL
12 BRAIN
13 EAR(S)
14 EYE(S)
15 NOSE
16 TEETH
17 MOUTH
18 OTHER FACIAL SOFT TISSUE
19 FACIAL BONES
20 MULTIPLE INJURY - NECK
21 VERTEBRAE - NECK
22 DISC - NECK
23 SPINAL CORD - NECK
24 LARYNX
25 SOFT TISSUE - NECK
26 TRACHEA
30 MULTIPLE UPPER EXTREMITIES
31 UPPER ARM INC:CLAVICLE SCPAULA
32 ELBOW
33 LOWER ARM
34 WRIST
35 HAND
36 FINGER(S)
37 THUMB
38 SHOULDER(S)
39 WRIST(S) & HAND(S)
40 MULTIPLE TRUNK
41 UPPER BACK AREA (THORACIC)
42 LOW BACK AREA (LUMBAR)
43 DISC - TRUNK
44 CHEST(RIBS,STERNUM,SOFT TISUE)
45 SACRUM AND COCCYX
46 PELVIS
47 SPINAL CORD - TRUNK
48 INTERNAL ORGANS
49 HEART
50 MULTIPLE LOWER EXTREMITIES
51 HIP
52 THIGH (UPPER LEG)
53 KNEE
54 LOWER LEG
55 ANKLE
56 FOOT
57 TOE(S)
58 GREAT TOE
60 LUNG
61 ABDOMEN INCLUDING GROIN
62 BUTTOCKS
63 LUMBAR/SACRAL VERTEBRAE -TRUNK
64 ARTIFICAL APPLIANCE/BRACES ETC
65 INSUFFICANT INFO TO IDENTIFY
66 NO PHYSICAL INJURY
90 MULTIPLE BODY PARTS
91 BODY SYSTEM/MULTIPLE BODY SYS
99 TEXAS EDI ONLY BODY AS A WHOLE
Multiple Selection / Type to Search
31c. Cause of Injury Category
*
Select one.
Burn or Scald – Heat or Cold Exposures
Caught In, Under or Between
Cut, Puncture, Scrape
Fall, Slip or Trip Injury
Motor Vehicle
Strain or Repetitive Motion
Striking Against or Stepping On
Struck or Injured by
Rubbed by or Abrasion
Miscellaneous Causes
31c. Cause of Injury
*
Select the appropriate Cause of Injury Category from the list above.
Burn or Scald – Heat or Cold Exposures
Chemicals (01)
Hot Objects or Substances (02)
Temperature Extremes (03)
Fire or Flame (04)
Steam or Hot Fluids (05)
Dust, Gases, Fumes or Vapors (06)
Welding Operation (07)
Radiation (08)
Contact With, NOC (09)
Cold Objects or Substances (11)
Abnormal Air Pressure (14)
Electrical Current (84)
Caught In, Under or Between
Machine or Machinery (10)
Object Handled (12)
Caught In, Under or Between NOC (13)
Collapsing Materials (Slides of Earth) (20)
Cut, Puncture, Scrape
Broken Glass (15)
Hand Tool, Utensil; Not Powered (16)
Object Being Lifted or Handled (17)
Powered Hand Tool, Appliance (18)
Cut, Puncture, Scrape, NOC (19)
Fall, Slip or Trip Injury
From Different Level (Elevation) (25)
From Ladder or Scaffolding (26)
From Liquid or Grease Spills (27)
Into Openings (28)
On Same Level (29)
Slip, or Trip, Did Not Fall (30)
Fall, Slip or Trip, NOC (31)
On Ice or Snow (32)
On Stairs (33)
Motor Vehicle
Crash of Water Vehicle (40)
Crash of Rail Vehicle (41)
Collision or Sideswipe With Another Vehicle (45)
Collision with a Fixed Object (46)
Crash of Airplane (47)
Vehicle Upset (48)
Motor Vehicle, NOC (50)
Strain or Repetitive Motion
Continual Noise (52)
Twisting (53)
Jumping or Leaping (54)
Holding or Carrying (55)
Lifting (56)
Pushing or Pulling (57
Reaching (58)
Using Tool or Machinery (59)
Strain or Injury By, NOC (60)
Wielding or Throwing (61)
Repetitive Motion (97)
Striking Against or Stepping On
Moving Part of Machine (65)
Object Being Lifted or Handled (66)
Repetitive Motion (94)
Rubbed or Abraded, NOC (95)
Struck or Injured by
Fellow Worker, Patient or Other Person (74)
Falling or Flying Object (75)
Hand Tool or Machine in Use (76)
Motor Vehicle (77)
Moving Parts of Machine (78)
Object Being Lifted or Handled (79)
Object Handled By Others (80)
Struck or Injured, NOC (81)
Animal or Insect (85)
Explosion or Flare Back (86)
Rubbed by or Abrasion
Repetitive Motion (94)
Rubbed or Abraded, NOC (95)
Miscellaneous Causes
Absorption, Ingestion or Inhalation, NOC (82)
Foreign Matter (Body) in Eye(s) (87)
Person in Act of a Crime (89)
Other Than Physical Cause of Injury (90)
Mold (91)
Terrorism (96)
Cumulative, NOC (98)
Other - Miscellaneous, NOC (99)
Hidden
31c. Cause(s) of Injury
*
01 BURN: ACID CHEMICALS
02 HOT OBJECT OR SUBSTANCES
03 TEMPERATURE EXTREMES
04 FIRE OR FLAME
05 STEAM OR HOT FLUIDS
06 DUST, GASES, FUMES OR VAPORS
07 BURN: WELDING OPERATIONS
08 BURN: RADIATION
09 CONTACT WITH, NOC
10 CAUGHT IN MACHINE OR MACHINERY
11 COLD OBJECT OR SUBSTANCES
12 CAUGHT IN OBJECT HANDLED
13 CAUGHT IN/UNDER OR BETWEEN,NOC
14 ABNORMAL AIR PRESSURE
15 CUT: BROKEN GLASS
16 CUT: HAND TOOL, NOT POWRD
17 OBJECT BEING LIFTED OR HANDLED
18 POWERED HAND TOOL, APPLIANCE
19 CAUGHT,PUNCTURED,SCRAPED,NOC
20 COLLAPSING MATERIALS
25 FALL DIFFERENT LEVEL(ELEVATION
26 FALL FROM LADDER OR SCAFFOLD
27 FALL: LIQUID OR GREASE SPILL
28 FALL INTO OPENINGS
29 FALL ON SAME LEVEL
30 SLIPPED, DID NOT FALL
31 FALL,SLIP OR TRIP, NOC
32 FALL ON ICE OR SNOW
33 FALL ON STAIRS
40 CRASH OF WATER VEHICLE
41 CRASH OF RAIL VEHICLE
45 VEHICLE: COLLISION WITH ANOTHR
46 VEHICLE: COLLISION WITH FIXED
47 CRASH OF AIRPLANE
48 VEHICLE UPSET
50 MOTOR VEHICLE, NOC
52 CONTINUAL NOISE
53 SPRAIN BY TWISTING
54 STRAIN: JUMPING
55 STRAIN: HOLDING/CARRYING
56 STRAIN: LIFTING
57 STRAIN: PUSHING OR PULLING
58 STRAIN: REACHING
59 STRAIN: USING TOOL OR MACHINE
60 STRAIN OR INJURY BY, NOC
61 WEILDING OR THROWING
65 STRIKING: MOVING PARTS/MACHINE
66 STRIKING: OBJECT LIFTED
67 SANDING, SCRAPING, CLEANING
68 STRIKING: STATIONARY OBJECT
69 STEPPING ON SHARP OBJECT
70 STRIKE AGAINST/STEPPING ON,NOC
74 STRUCK BY CO-WORKER/PATIENT
75 STRUCK BY: FALLING OBJECT
76 STRUCK: HAND TOOL OR MACHINE
77 STRUCK BY MOTOR VEHICLE
78 STRUCK BY MOVING PARTS MACHINE
79 STRUCK BY OBJECT LIFTED
80 STRUCK,OBJECT HANDLED BY OTHER
81 STRUCK OR INJURED, NOC
82 ABSORPTION,INGESTION,INHALATIO
83 PANDEMIC
84 ELECTRICAL CURRENT
85 ANIMAL OR INSECT
86 EXPLOSION OR FLARE BACK
87 FOREIGN MATTER(BODY) IN EYE(S)
88 ON FLOOR/TREATMENT MAT
89 PERSON IN ACT OF CRIME
90 OTHER THAN PHYSICAL CAUSES
91 MOLD
94 ABRADED: REPETITIVE MOTION
95 ABRADED: NOC
96 TERRORISM ONLY USE W/ CAT CODE
97 STRAIN: REPETITIVE MOTION
98 CUMULATIVE, NOC
99 OTHER MISC, NOC
Multiple Selection / Type to Search
32. Witness(es) to Injury - Give Full Name(s), if none state as such
*
33. Has Employee Returned to Work?
*
Yes
No
34. Date Employee Returned to Work
MM slash DD slash YYYY
35. Employee's Regular Occupation?
*
36. Has Employee Returned to Regular Occupation?
Yes
No
37. Preparer's Name
*
38. Preparer's Title
*
39a. Date Prepared
*
MM slash DD slash YYYY
39b. Preparer's Email Address
*
By pressing SUBMIT I certify that I am authorized to prepare this report on behalf of the employer and that the information is correct to the best of my knowledge.
*
I am authorized.
This form must be filed by the employer or an authorized agent/representative of the employer.