Massachusetts Agreement To Pay CompensationMassachusetts Agreement To Pay Compensation
Download the document to the computer for easy use
There are more pages to preview,Read on

FORM 113

DIA Board #
(If Known):

The Commonwealth of Massachusetts
Department of Industrial Accidents – Department 113
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

Print Form

AGREEMENT TO PAY COMPENSATION

This form should be used only for cases in which liability has been accepted. Codes and instructions on the reverse side.
E
M
P
L
O
Y
E
E

2. Date of Birth (mm/dd/yyyy): 3. Social Security Number*: 3a. No. of Dependents:

1. Employee’s Name (Last, First, MI):
4. Home Address (No., Street, City, State & Zip Code)
5. Employer’s Name & Address (No. , Street, City, State & Zip Code):

6. Self Insured:

Yes
If yes, Self-Insurer #:

No

7. Name of Workers’ Compensation Insurance Carrier, Address and Tel. No. (NOT LOCAL AGENT/ADMINISTRATOR)

8. Claim Representative’s Name & Telephone Number:

9. Insurer’s File Number:

10. DATE OF INJURY (mm/dd/yyyy):

11. If Employe