Insurer Notification of Termination for Workers' Compensation - Massachusetts 2026

Get Form
mass workers' comp settlement chart Preview on Page 1
See details
4.5 out of 5
43 votes
The document is a Form 106 from the Massachusetts Department of Industrial Accidents, used for notifying employees about the termination or modification of weekly compensation payments during a payment without prejudice period. It outlines necessary information such as insurer details, employee information, reasons for termination or modification, and required notifications to the employee.
DocHub Reviews
44 reviews
DocHub Reviews
23 ratings
15,005
10,000,000+
303
100,000+ users

Here's how it works

01. Edit your mass workers' comp settlement chart online
Type text, add images, blackout confidential details, add comments, highlights and more.
02. Sign it in a few clicks
Draw your signature, type it, upload its image, or use your mobile device as a signature pad.
03. Share your form with others
Send mass workers comp settlement chart via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out Insurer Notification of Termination for Workers' Compensation - Massachusetts

Form edit decoration
9.5
Ease of Setup
DocHub User Ratings on G2
9.0
Ease of Use
DocHub User Ratings on G2
  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering the Insurance Carrier's Name and Address in the designated fields. If applicable, indicate if you are self-insured and provide your self-insurer number.
  3. Fill in the Name & Address of the Insurer's Attorney along with their Telephone Number.
  4. Complete the Claim Representative's Name and their Telephone Number & Extension.
  5. Input the Insurer's Case File Number and confirm whether the insurer received the First Report of Injury (Form 101). If yes, include the date received.
  6. Provide Employee details: Name, Social Security Number, Address, Date of Birth, Date of Injury, and dates related to incapacity to earn wages.
  7. Specify grounds for termination in Box 19. Be concise but thorough; failure to provide adequate information may affect defenses under M.G.L. c 152.
  8. Finally, sign and date the form at the bottom before submitting it through our platform for processing.

Start using our platform today to streamline your document editing and ensure a smooth completion of your forms!

Fill out Insurer Notification of Termination for Workers' Compensation - Massachusetts online
It's free
Start now
be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.
Contact us

Upload your Insurer Notification of Termination for Workers' Compensation - Massachusetts to DocHub (once you’ve set up an account for this). If you need to complete fields in it, use appropriate tools from the upper pane. For example, add Signature Fields, assign each to specific person, and click on Sign → Request signatures from others. Change your message for your recipients and click Send Request. You can also send your form by fax or as a Signing link instead of using email (you’ll find these options by navigating to the Menu → Send)

If you go for analog ways of completing your Insurer Notification of Termination for Workers' Compensation - Massachusetts, it is simple to download your file for printing. Search DocHub’s Forms & Templates catalog to find the exact document template you require and open it for editing or download it on your device in the format of your liking. It is possible to complete your form electronically and place your handwritten signature on it after printing or eSign your document with DocHub.

Massachusetts workers compensation judges follow a going and coming rule that states employees who are injured on their way to work or just after leaving work are not eligible for workers compensation.
The Massachusetts Workers Compensation Act requires you to cover all workers at all times, covering: Medical care for work-related injuries or illnesses. Partial wage replacement when your employees need time off to recover.
The days dont need to be consecutive. You have 7 calendar days (except for Sundays and legal holidays) after the injured workers 5th day of full or partial disability to report the injury to the DIA. You need to file the Form 101 - Employers First Report of Injury/Fatality via a DIA online account.

Related Searches

Massachusetts workers' compensation case Lookup How to file a workers comp Claim in Massachusetts MA workers comp form Massachusetts workers' compensation law MA workers' compensation insurance Workers Comp Massachusetts phone number Conference memo mass dia Check workers comp status

Security and compliance

At DocHub, your data security is our priority. We follow HIPAA, SOC2, GDPR, and other standards, so you can work on your documents with confidence.

Learn more
ccpa2
pci-dss
gdpr-compliance
hipaa
soc-compliance

People also ask

The Massachusetts Workers Compensation Act requires you to cover all workers at all times, covering: Medical care for work-related injuries or illnesses. Partial wage replacement when your employees need time off to recover.
Can I be fired while Im out on workers compensation? Unless your union contract, or individual contract of hire, requires it, an employer doesnt have to hold your job open while you cant work due to an on-the-job injury.
Up to 260 weeks or 5 years. However, you are entitled to 7 years of benefits when combining Temporary Total and Temporary Partial Disability. For example, if you receive 3 years of temporary total disability benefits, you cannot receive an additional 5 years of partial disability benefits.
What is the statute of limitations? Under the workers compensation law, (MGL c. 152, 41) for injuries on or after January 1, 1986, a claim must be filed with the insurer within 4 years of the date you become aware of a connection between your injury/illness and your employment.
In Massachusetts, there is a three year statute of limitations for personal injury cases. That is, you have three years from the date of the injury to file a lawsuit under the law.

Related links

Massachusetts Workers Compensation Guide For Injured

If you receive a Form 106 and you receive notification of termination of benefits, be sure to consult an attorney to discuss your rights and responsibilities.

Learn more
Medicare

This transmittal introduces Chapter 40, Hospital and Hospital Health Care Complex Cost Report,. Form CMS-2552-10, which contains instructions for the completion

Learn more
DIA Numerical Form List

Form 107 - Insurers Notification of Acceptance, Resumption, Termination or Modification of Weekly Compensation - can only be filed via our online CMS system

Learn more

Try more PDF tools

Edit & Annotate
Edit PDF
Add Fillable Fields
Create PDF
Insert and Merge
Add Page Numbers
Rotate Pages
Delete Pages
Convert
Word to PDF
TXT to PDF
HTML to PDF
CSV to PDF
PPT to PDF
RTF to PDF
JPG/JPEG to PDF
PNG to PDF
Collaborate & Share
Add Comments
Fax
PDF Status
Sign & Send
Sign a PDF
Send for Signing
Protect PDF
Set PDF password
Readable PDF
Certify PDF
PDF Audit Trail
Others
Search for PDF
Export
Download
Flatten Fields
Print out
If you believe that this page should be taken down, please follow our DMCA take down process here
support@dochub.com
17 Station St., Ste. 303 Brookline, MA 02445
Google Play App Store
© 2026 DocHub, LLC
All Rights Reserved.
Products
PDF Editor
Forms & Templates
Sign Documents
Server Status
Pricing
Forms Library
Features
Functions
Company
About
Terms of Service
Privacy Notice
Legal Hub
E-Signature Compliance
Support
Release Notes
Bug Bounty Program
Resources
Blog
DocHub Mobile App
pdfFiller
US Legal Forms
SignNow
altaFlow
Instapage
What's New
New
DocHub v6.6.0 - @mentions, AI assistant and more
Contact us
support@dochub.com
17 Station St., Ste. 303 Brookline, MA 02445
Google Play App Store
© 2026 DocHub, LLC
All Rights Reserved.