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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
*
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
10. Hourly Wage
11. Piece or Hourly Worker?
Piece
Hourly
12. Hours Worked Per Day
13. Days Worked Per Week
14a. Average 52-week Wage
Please enter a dollar amount.
14b. Average 52-week Wage Amount
Estimated
Actual
Employer Information
15. Employer Name
*
16. Employer Self-Insured?
Yes
No
17. Federal Tax ID
18a. Street Address
*
18b. City
*
18c. State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
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
18d. Zip Code
*
19. Employer Phone
*
20. 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
21. Insurance Carrier: Name and Address of Branch Responsible for This Case
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
22. Worker's Compensation Policy Number
23. OSHA Case File Number
(if applicable)
Injury Information
24. Date of Injury
*
MM slash DD slash YYYY
25. Time of Injury
:
Hours
Minutes
AM
PM
AM/PM
26. Source 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
26. Source of Injury
*
Select the appropriate Source 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)
27. Address Where Injury Occurred
28. On Employer's Premises?
Yes
No
29. Employer Location Code
30. Regular Occupation
*
31. Regular Occupation When Injured?
Yes
No
32. To Whom Was Injury Reported?
*
33. Date Reported
*
MM slash DD slash YYYY
34. 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
35. 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
36. Physician Name and Address
37. Hospital Name and Address
38. Describe How Injury Occurred
*
(e.g., Struck by__, Fell from__, Exposed to...)
39. If Employee Has Returned to Work, Date of Return
MM slash DD slash YYYY
40. Returned to Regular Occupation?
*
Yes
No
41. Preparer's Name
*
42. Preparer's Title
*
43. Date Prepared
*
MM slash DD slash YYYY
44. Preparer's Email Address
*
