Massachusetts form 127 2026

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The document is a form from the Massachusetts Department of Industrial Accidents used to compute the average weekly wage for an injured employee. It requires information about the employer, employee, dependents, dates of injury and employment, and a detailed record of wages earned over the 52 weeks prior to the injury. The form also includes sections for additional benefits and requires signatures for validation.

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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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Versions	Form popularity	Fillable & printable
2013	4.8 Satisfied (121 Votes)
2005	4.4 Satisfied (93 Votes)

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