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Massachusetts form 127 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the Employer’s Name and Address in the designated fields. This information is crucial for identifying the responsible party.
- Next, input the Insurer’s Case File # and DIA Board # if known. These numbers help streamline communication with the Department of Industrial Accidents.
- Fill in the Employee’s Name and Address accurately to ensure proper identification.
- Indicate the number of dependent children and other dependents, as this information may affect wage calculations.
- Record important dates: Date of Injury, Date of Employment, and Date of Disability using the mm/dd/yyyy format.
- Complete the wage section by listing gross amounts earned each week for up to 52 weeks prior to the injury. If applicable, substitute wages from a fellow employee in the same class.
- Finally, provide your signature as the employer/preparer along with the date signed to validate the form.
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