Massachusetts Employer's First Report of Injury Or FatalityMassachusetts Employer's First Report of Injury Or Fatality
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FORM 101

The Commonwealth of Massachusetts
Department of Industrial Accidents – Department 101

DIA USE ONLY

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

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EMPLOYER’S FIRST REPORT OF INJURY
OR FATALITY
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.
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1. Employee’s Name (Last, First, MI):

2. Home Telephone Number:

5. Home Address (No., Street, City, State & Zip Code):

3. Social Security Number*:

5a. Native Language Code: 6. Marital Status:

F

7. No. of Dependents:

M

Other:________________
9. Date of Birth (mm/dd/yyyy):

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

4. Sex:
M

S

10. Average Weekly Wage