Form 101 Massachusetts – Fill Out and Use This PDF

The 101 Massachusetts form, officially known as the Employer’s First Report of Injury or Fatality, is a critical document required by the Commonwealth of Massachusetts Department of Industrial Accidents. Employers must file this form following an incident that results in an employee's death or incapacitates an employee for five or more days, preventing them from earning wages. It plays a vital role in the workers' compensation process, ensuring that the incident is documented and necessary actions are taken. For those needing to complete this form, click the button below to get started.

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Form 101 Massachusetts PDF Details

In Massachusetts, ensuring a safe working environment and accurately reporting any workplace injuries or fatalities is both a legal requirement and a moral imperative for employers. The Form 101 is a critical document in this process, as outlined by The Commonwealth of Massachusetts Department of Industrial Accidents. This form serves as the Employer’s First Report of Injury or Fatality and must be filed in the unfortunate event of an employee suffering an injury that results in death or requires five or more calendar days of total or partial incapacity from earning wages. Detailed within the form are sections requiring information about the employee, the injury or fatality, and specifics about the employer, including their workers' compensation insurance carrier. Additionally, it includes a section for the preparer’s information to ensure accountability and clarity in the reports filed. Employers are urged to file this form within seven calendar days, excluding Sundays and legal holidays, from when notice of an injury that falls under the reporting requirements is received. Failing to submit this report can lead to penalties, underlining the importance the state places on workplace safety and accurate reporting. This document, however, does not constitute an employee’s claim for workers' compensation benefits but is a mandatory step in the reporting process that can aid in such claims.

Question	Answer
Form Name	Form 101 Massachusetts
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	Brucellosis, Massachusetts, amazon, 20a

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FORM 101	The Commonwealth of Massachusetts
	Department of Industrial Accidents – Department 101
	1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
	Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470
	http://www.mass.gov/dia

EMPLOYER’S FIRST REPORT OF INJURY

OR FATALITY

DIA USE ONLY

THIS FORM MUST BE FILED BY THE EMPLOYER IN THE EVENT OF AN INJURY THAT RESULTS IN DEATH OR FIVE OR MORE CALENDAR DAYS OF TOTAL OR PARTIAL INCAPACITY FROM EARNING WAGES.

INSTRUCTIONS AND CODES ON THE REVERSE SIDE - Please Print Legibly or Type - Unreadable forms will be returned.

E	1. Employee’s Name (Last, First, MI):		2. Home Telephone Number:		3. Social Security Number*: 4. Sex:
E
M								M	F
P
P	5. Home Address (No., Street, City, State & Zip Code):			5a. Native Language Code:		6. Marital Status:		7. No. of Dependents:
L	5. Home Address (No., Street, City, State & Zip Code):			5a. Native Language Code:		6. Marital Status:		7. No. of Dependents:
L
O						M	S
				Other:________________		M	S

Y
Y
E	8. Date of Hire (mm/dd/yyyy):	9. Date of Birth (mm/dd/yyyy):			10. Average Weekly Wage:
E
E					$		Estimated		Actual
	11. Employer’s Name:				12. Federal Tax I.D. Number:
	11. Employer’s Name:				12. Federal Tax I.D. Number:
E	13. Employer’s Address (No., Street, City, State & Zip Code):				14. Employer’s Telephone Number:
M					14. Employer’s Telephone Number:
M
P
L					15. Industry Code (See Reverse Side):
O

Y16. Workers’ Compensation Insurance Carrier and Tel. No. (NOT LOCAL AGENT/ADMINISTRATOR): 17. W.C. Policy Number:

R	18. Self-Insured?	Yes	No		19. Business Type :		Service Wholesale	Mfg.
	18. Self-Insured?	Yes	No		19. Business Type :		Service Wholesale	Mfg.
	If Yes, Self-Insurer Number:				Retail	Other ________________________
					20a. Insurer’s Case/Claim File No.:
	20. DATE OF INJURY (mm/dd/yyyy):
I	21. Was Employee Injured on Employer’s Premises?			Yes	No 22. Location of Injury if not on Employer’s Premises:
I
N
J	23. FIRST day of Total or Partial Incapacity to Earn Wages				24. FIFTH day of Total or Partial Incapacity to Earn Wages
J
U	(mm/dd/yyyy):				(mm/dd/yyyy):
U
R
Y 25. If Employee has Died, Date of Death (mm/dd/yyyy):					26. Source of Injury (Chemicals, Machinery, etc.):

N27. Briefly Describe How Injury/Exposure Occurred and Body Part(s) involved:

28. Person to Whom Injury was Reported (list position):

29. Date Reported (mm/dd/yyyy):

30. Date Reported as work related

(mm/dd/yyyy):

31. Injury Code(s)

Body Part Code(s)

32. Witness(es) to Injury - Give Full Name(s), if none state as such:

to body part

33. Has Employee Returned to Work?

Yes

34. Date Employee Returned to Work(mm/dd/yyyy):

35. Employee’s Regular Occupation:

36. Has Employee Returned to Regular Occupation:

Yes

P 37. PREPARER’S Name (SEE INSTRUCTIONS ON REVERSE SIDE):

38. PREPARER’S Title:

A 39. PREPARER’S Signature (SEE INSTRUCTIONS ON REVERSE SIDE):

40. Date Prepared (mm/dd/yyyy):

40a. PREPARER’S e-mail address:

*Disclosure of Social Security Number is Voluntary. It will aid in the processing of your report.

Form 101 - Revised 7/2010 - Reproduce as needed.

THIS FORM DOES NOT CONSTITUTE AN EMPLOYEE’S CLAIM FOR BENEFITS UNDER WORKERS’ COMPENSATION.

EMPLOYER’S FIRST REPORT OF INJURY OR FATALITY

FILING INSTRUCTIONS

1.WHEN TO FILE: File this form within 7 calendar days, not including Sundays and legal holidays, of receipt of notice of any injury alleged to have arisen out of and in the course of employment, which totally or partially incapacitates an employee for a period of 5 or more calendar days from earning wages. This form is not an admission of liability, but must be filed even though the Employer may believe that the Employee is not injured, or that the Employee is not entitled to benefits under M.G.L. Chapter 152.

2.WHERE TO FILE: This form should be mailed to the Department of Industrial Accidents at the address shown on the front of the form. Copies must also be provided to the Employee and to the Employer’s Workers’ Compensation insurer.

3.PENALTIES: Failure to report injuries on this form may result in a fine of $100.00 in accordance with M.G.L. Chapter 152, Section 6.

4.EMPLOYER’S NAME & SIGNATURE IN BOXES 37 & 39: This form must be filed by the employer or an authorized agent/representative of the employer.

NATIVE LANGUAGE CODES

1 – English / 2 – Portuguese / 3 – Haitian Creole / 4 – Spanish / 5 – Chinese / 6 – Vietnamese / 7 – Cape Verdean / 9 – Other

INDUSTRY CODES

Agriculture, Forestry and Fishing		28 Chemicals and Allied Products		51 Wholesale Trade - Non-durable Goods		78	Motion Pictures
01	Agriculture Production - Crops	29	Petroleum and Coal Products			79	Amusements and Recreation Services
02	Agriculture Production - Livestock	30	Rubber and Misc. Plastic Products	Retail Trade		80	Health Services
07	Agricultural Services	31	Leather and Leather Products	52	Building Materials and Garden Supplies	81	Legal Services
08	Forestry	32	Stone, Clay and Glass Products	53	General Merchandizing	82	Educational Services
09	Fishing, Hunting and Trapping	33	Primary Metal Industries	54	Food Stores	83	Social Services
Mining		34	Fabricated Metal Products	55	Automotive Dealers and Service Stations	84	Museums, Botanical, Zoological Gardens
		35	Industrial Machinery and Equipment	56 Apparel and Accessory Stores		86	Membership Organizations
10	Metal Mining
		36	Electronic and Other Electrical Equipment	57	Furniture and Home Furnishing Stores	87	Engineering and Management Services
12	Coal Mining
		37	Transportation Equipment	58	Eating and Drinking Establishments	88	Private Households
13	Oil and Natural Gas
		38	Instruments and Related Products	59	Miscellaneous Retail	89	Services, NEC
14	Nonmetallic Minerals, Except Fuels
		39	Miscellaneous Manufacturing Industries

Construction		Transportation and Public Utilities		Finance, Insurance and Real Estate		Public Administration
				60	Depository Institutions	91	Executive, Legislative and Garden
15	General Building Contractors
		40	Railroad Transportation
				61	Non-depository Institutions	92	Justice, Public Order, and Safety
16	Heavy Construction, Ex. Building
		41	Local and Interurban Passenger Transit
				62	Security and Commodity Brokers	93	Finance, Taxation, and Monetary Benefits
17	Special Trade Contractors
		42	Trucking and Warehousing
				63	Insurance Carriers	94	Administration of Human Services

		43	U.S. Postal Service
Manufacturing				64	Insurance Agents, Brokers and Service	95	Environmental Quality and Housing
		44	Water Transportation
20	Food and Kindred Products			65	Real Estate	96	Administration of Economic Program
		45	Transportation by Air
21	Tobacco Products			67	Holding and Other Investment Officers	97	National Security and International Affairs
		46	Pipelines, Except Natural Gas
22	Textile Mill Products
		47	Transportation Services	Services
23	Apparel and Other Textile Products					Non-classifiable Establishments
		48	Communications	70 Hotels and Other Lodging Places
24	Lumber and Wood Products					99	Non-classifiable Establishments
		49	Electric, Gas and Sanitary Services	72	Personal Services
25	Furniture and Fixtures
				73	Business Services
26	Paper and Allied Products	Wholesale Trade
				75	Auto Repair Services and Parking
27	Printing and Publishing
		50	Wholesale Trade - Durable Goods
				76	Miscellaneous Repair Services

NATURE OF INJURY OR ILLNESS CODES

100	Amputation or Enucleation	157	Tuberculosis	281	Aluminosis	Other
110	Asphyxia or Strangulation Etc.	159	Other Infective or Parasitic Diseases	282	Anthracosis	265	Carpal Tunnel Syndrome
120	Burns (Heat)	Dermatitis		283	Asbestosis	510	Cardiovascular and Other Conditions
130	Burns (Chemical)	180	Dermatitis, UNS*	284	Byssinosis		of the Circulatory System
140	Concussion	183	Primary Infections of the Skin	285	Siderosis	520	Complications Peculiar to Medical Care
160	Contusion, Crushing, Bruise	184	Other Skin Conditions	286	Silicosis	500	Effects of Changes in Atmospheric
170	Cut, Laceration, Puncture	185	Dermatitis, Allergenic or Contact	287	Other Pneumoconioses		Pressure
190	Dislocation	189	Skin Condition, NEC**	289	Pneumoconiosis and Tuberculosis	240	Effects of Environmental Heat
200	Electric Shock, Electrocution		Poisoning Systemic		Nervous System, Conditions of	220	Effects of Exposure to Low Temperature
210	Fracture	270	Poisoning, Systemic, UNS*	560	Nervous System, Conditions of - NEC**	530	Eye, other Diseases of the Eye
250	Hernia, Rupture	271	Due to Toxic Materials other than Lead	561	Diseases of the Central Nervous	230	Hearing Loss or Impairment
300	Scratches, Abrasions	272	Diseases of the Blood and Blood Forming		System	991	Heart Condition ,Excludes Heart Attack
310	Sprains, Strains		Organs	562	Diseases of the Nerves and Peripheral	320	Hemorrhoids
400	Multiple Injuries	273	Upper Respiratory Conditions		Ganglia	330	Hepatitis, Serum and Infective
900	No Injury	274	Influenza, Pneumonia, Etc.		Neoplasm Tumor	275	Hepatitis, Toxic
950	Damage to Prosthetic Devices	276	Other Diseases of the Gastro-Intestinal	550	Neoplasm Tumor, UNS*	260	Inflammation of Joints, Etc.
995	No Other Injury, NEC**		Tract	551	Malignant	540	Mental Disorders
999	Non-classifiable	278	Effects of Lead	552	Benign	900	No Illness
	Infective or Parasitic Disease	279 Other Toxic Effects of One System Only			Radiation Effects	999	Non-classifiable
150	Infective or Parasitic Disease, UNS*	Respiratory Systems, Conditions of		290	Radiation Effects, UNS*	990	Occupational Disease, NEC**
151	Amebiasis	570	Respiratory Systems, Conditions of	291	Non-Ionizing Radiation	580	Symptoms and Ill-defined Conditions
152	Anthrax	571	Upper Respiratory	292	Microwaves
153	Brucellosis	572	Asthma, Influenza, Pneumonia	293	Ionizing Radiation - X-Ray
154	Conjunctivitis and Opthalmia		Pneumoconiosis	294	Ionizing Radiation - Isotopes
156	Tetanus	280	Pneumoconiosis	295	Welder’s Flash

BODY PART AFFECTED CODES

Head		160	Skull	398	Upper Extremities, Multiple	513	Knee(s)
100	Head, UNS*	198	Head Multiple	400	Trunk, UNS*	515	Lower Leg(s)
110	Brain	200	Neck & Cervical Vertebrae	410	Abdomen, Internal Organs,	518	Leg(s), Multiple
120	Ear(s), UNS*	UPPER EXTREMITIES			Inguinal Hernia	519	Leg(s), NEC**
121	Ear(s), External	300	Upper Extremities, NEC**	420	Back	520	Ankle(s)
124	Ear(s), Internal	310	Arm(s), UNS*	430	Chest, Ribs, Breastbone,	530	Foot or Feet, Not Ankle
130	Eye(s), UNS*	311	Upper Arm		Internal Organs	540	Toe(s)
140	Face, UNS*	313	Elbow(s)	440	Hip(s)..,Pelvis, Organs and	598	Lower Extremities, Multiple
141	Jaw, Chin	315	Forearm(s)		Buttocks	700	MULTIPLE PARTS
144	Mouth and Throat (vocal chords, larynx)	318	Arm(s), Multiple	450	Shoulder(s)		Applies when more than one major body part
146	Nose	319	Arm(s), NEC**	498	Trunk, Multiple		as been effected such as an arm and a leg
148	Face, Multiple Parts	320	Wrist(s)	LOWER EXTREMITIES		999	NON-CLASSIFIABLE - Insufficient infor-
149	Face, NEC**	330	Hand(s), Not Wrists or Fingers	500	Lower Extremities		mation to identify part of body effected. In-
150	Scalp	340	Finger(s)	510	Leg(s), UNS*		cludes damage to prosthetic devises.

*UNS - UNSPECIFIED

**NEC - NOT ELSEWHERE CLASSIFIED

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1. While filling in the PREPARER, ensure to incorporate all of the necessary blank fields in its relevant area. This will help expedite the process, which allows your details to be processed without delay and correctly.

2. Once your current task is complete, take the next step – fill out all of these fields - DATE OF INJURY mmddyyyy, a Insurers CaseClaim File No, Was Employee Injured on Employers, Location of Injury if not on, FIRST day of Total or Partial, FIFTH day of Total or Partial, If Employee has Died Date of, Source of Injury Chemicals, Briefly Describe How, Person to Whom Injury was, Date Reported mmddyyyy, Date Reported as work related, Injury Codes a, to body part, and Body Part Codes a with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Always be extremely attentive when completing If Employee has Died Date of and to body part, because this is the part where a lot of people make a few mistakes.

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