Massachusetts Form 127 PDF Details

In Massachusetts, the navigation of workers' compensation proceedings involves the meticulous computation and submission of various documents, among which the Form 127 stands out as a critical element. This document, designated by the Commonwealth of Massachusetts Department of Industrial Accidents located on Congress Street in Boston, serves a fundamental purpose in the workers' compensation claim process. Form 127, formally referred to as the Average Weekly Wage Computation Schedule, is an essential tool for calculating the claimant’s average weekly wage over a specified period, generally the 52 weeks preceding an accident. This calculation is pivotal as it influences the benefits an injured worker can receive. The form requires detailed input ranging from the employer and insurer's information to specifics about the employee such as name, address, employment, disability status, and a comprehensive breakdown of wages earned before taxes. Additionally, it accounts for variables like dependent children, other dependents, and any accommodations such as furnished room or additional earnings like tips. Verification by the employer or a preparer validates the accuracy of the recorded information, ensuring that the document aptly reflects the injured worker's earnings or, when necessary, those of a colleague within the same employment classification for periods when the claimant has worked less than a year. The precision and integrity of the Form 127 not only facilitate a fair assessment of claims but also uphold the principle of providing support to workers compromised by workplace accidents, highlighting the broader commitment to workers’ welfare within Massachusetts.

QuestionAnswer
Form NameMassachusetts Form 127
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmassachusetts average weekly wage computaion forms, mass form 127, frm 127, form 127

Form Preview Example

FORM 127

The Commonwealth of Massachusetts

Department of Industrial Accidents

 

 

1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017

 

Info. Line 800 323-3249 ext. 7470 in Mass. Outside Mass. - 617-727-4900 ext. 7470

 

http://www.mass.gov/dia

 

AVERAGE WEEKLY WAGE COMPUTATION SCHEDULE

DIA USE ONLY

Print or Type

1. Employer’s Name and Address:

2.

Insurer’s Case File #:

 

 

 

 

3.

DIA Board # (if known):

 

 

 

4. Employee’s Name and Address:

5.

# of dependent children:

 

 

 

 

6.

# of other dependents:

7. Date of Injury (mm/dd/yyyy):

8. Date of Disability (mm/dd/yyyy):

9. Date of Employment (mm/dd/yyyy):

10. Has employee been certified by U.S. Veterans Administration for any type of disability?

Yes

No

Indicate only those wages earned by the injured worker during the 52 week period immediately preceding the accident. If the injured employee has worked for less than 52 weeks, report wages from the time worked and, for the remaining weeks on this schedule, substitute wages of a fellow employee in the same class of employment who has worked for one year or more.

11.

Year:

 

 

Year:

 

 

Year:

 

 

 

 

 

 

 

 

Week

Week Ending

Gross Amount

Week

Week Ending

Gross Amount

Week

Week Ending

 

Gross Amount

Before Taxes

Before Taxes

 

Before Taxes

No.

Month

Day

 

No.

Month Day

 

No.

Month

Day

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

 

 

19

 

 

37

 

 

 

 

2

 

 

 

20

 

 

38

 

 

 

 

3

 

 

 

21

 

 

39

 

 

 

 

4

 

 

 

22

 

 

40

 

 

 

 

5

 

 

 

23

 

 

41

 

 

 

 

6

 

 

 

24

 

 

42

 

 

 

 

7

 

 

 

25

 

 

43

 

 

 

 

8

 

 

 

26

 

 

44

 

 

 

 

9

 

 

 

27

 

 

45

 

 

 

 

10

 

 

 

28

 

 

46

 

 

 

 

11

 

 

 

29

 

 

47

 

 

 

 

12

 

 

 

30

 

 

48

 

 

 

 

13

 

 

 

31

 

 

49

 

 

 

 

14

 

 

 

32

 

 

50

 

 

 

 

15

 

 

 

33

 

 

51

 

 

 

 

16

 

 

 

34

 

 

52

 

 

 

 

17

 

 

 

35

 

 

 

Total:

 

 

18

 

 

 

36

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. Was room furnished to the employee?

Yes No

13. If tips or other benefits were earned, describe and state value per week:

THIS IS A TRUE COPY OF THE PAYROLL RECORD OF THE ABOVE NAMED EMPLOYEE OR FELLOW EMPLOYEE IN THE SAME CLASS OF EMPLOYEMENT

 

14. Name of Fellow Employee (if

15. Employer/Preparer Signature:

16. Date Signed (mm/dd/yyyy):

 

applicable):

 

 

 

 

 

 

 

Make any comments on the reverse side of this form or on a separate sheet.

Form 127 – Revised 87/2013

 

 

 

Reproduce as needed.

Comments:

How to Edit Massachusetts Form 127 Online for Free

With the help of the online PDF editor by FormsPal, you can fill in or modify week yyyy mass here and now. In order to make our editor better and easier to use, we constantly design new features, taking into consideration feedback coming from our users. Starting is easy! All you should do is adhere to the following simple steps down below:

Step 1: Click on the "Get Form" button in the top part of this page to open our PDF tool.

Step 2: The editor helps you customize PDF files in a variety of ways. Modify it with any text, adjust original content, and place in a signature - all readily available!

Completing this PDF will require attentiveness. Ensure that all mandatory blanks are filled out properly.

1. It is very important complete the week yyyy mass accurately, so be careful while filling out the parts comprising all these blank fields:

Stage # 1 in completing dia form 127

2. The next step is to complete the following blank fields: Month Day, Week No, Month Day, Week No, Month Day, Total, Was room furnished to the employee, If tips or other benefits were, Yes No, and THIS IS A TRUE COPY OF THE PAYROLL.

Writing section 2 of dia form 127

When it comes to Week No and THIS IS A TRUE COPY OF THE PAYROLL, be certain that you take a second look in this current part. Both of these are the key fields in the file.

3. The following portion is all about Name of Fellow Employee if, Make any comments on the reverse, and Reproduce as needed - complete each one of these blank fields.

Stage number 3 of filling in dia form 127

4. It is time to fill out this next form section! Here you will get all of these Comments fields to fill in.

Writing segment 4 in dia form 127

Step 3: Just after double-checking the entries, hit "Done" and you are done and dusted! Join us today and instantly get access to week yyyy mass, available for downloading. Every edit made is handily saved , which enables you to modify the pdf later on if required. When using FormsPal, you can complete forms without the need to be concerned about information breaches or entries being shared. Our protected system makes sure that your private data is maintained safely.

Massachusetts Form 127 isn’t the one you’re looking for?

Related Documents