Fill Your Massachusetts 127 Form

Guidelines on Filling in Massachusetts 127

Filling out the Massachusetts 127 form is a straightforward process that requires attention to detail. This form is used to compute the average weekly wage for employees in the case of industrial accidents. By providing accurate and detailed information, you are ensuring the correct calculation of benefits. Below are the steps to fill out the form accurately.

1. Employer’s Name and Address: Enter the full legal name and address of the employer.
2. Insurer’s Case File #: Input the case file number assigned by the insurer.
3. DIA Board # (if known): Fill in the Department of Industrial Accidents Board number if it is known.
4. Employee’s Name and Address: Provide the employee's full name and address.
5. # of dependent children: Enter the number of dependent children the employee has.
6. # of other dependents: State the number of other dependents relying on the employee.
7. Date of Injury (mm/dd/yyyy): Fill in the date when the injury occurred.
8. Date of Disability (mm/dd/yyyy): Enter the date when the disability began.
9. Date of Employment (mm/dd/yyyy): Provide the date the employee started working with the employer.
10. If the employee has been certified by the U.S. Veterans Administration for any type of disability, mark Yes. Otherwise, select No.
11. Under the sections for wages, insert the year, and for each week (week number, month, day), input the gross amount before taxes. Do this for all applicable 52 weeks. If the employee worked less than 52 weeks, substitute with a fellow employee’s wages as instructed.
12. Was room furnished to the employee? Check Yes or No as applicable.
13. For tips or other benefits, describe them and provide their value per week.
14. If wages are based on a fellow employee’s wages, enter the Name of Fellow Employee.
15. Employer/Preparer Signature: The form must be signed by the employer or the individual preparing the form.
16. Date Signed (mm/dd/yyyy): Enter the date the form was signed.

Remember to review all information for accuracy before signing the form. Any additional comments or explanations can be made on the reverse side of the form or on a separate sheet. Accurate completion of this form is essential for the proper handling of wage computations in relation to industrial accidents.

What is the Massachusetts Form 127, and why is it important?

Massachusetts Form 127, known as the Average Weekly Wage Computation Schedule, is a crucial document for the Department of Industrial Accidents in Massachusetts. It's designed to accurately calculate an injured worker's average weekly wage based on their earnings in the 52 weeks prior to their accident. This figure is significantly important because it serves as a basis for determining the compensation benefits an injured employee might be entitled to under workers' compensation laws.

Who needs to fill out the Form 127?

This form must be filled out by the employer of the injured worker. It requires detailed information regarding the employee's wages, including any tips or other benefits received, to ensure a fair assessment of their average weekly earnings. This information helps in calculating the correct compensation benefits in the event of work-related injuries or disabilities.

What information is needed to complete Form 127?

To complete Form 127, the following information is required: employer’s name and address, insurer’s case file number, DIA Board number (if known), employee’s name and address, number of dependent children, number of other dependents, dates of injury, disability, and employment, whether the employee has been certified with a disability by the U.S. Veterans Administration, detailed weekly earnings for the 52 weeks preceding the accident, information on whether room was furnished to the employee, and any tips or other benefits earned. A true copy of the payroll record is also required to verify the provided information.

How does Form 127 affect workers' compensation benefits?

The information submitted on Form 127 directly impacts the calculation of workers' compensation benefits. The calculated average weekly wage determines the financial benefits an injured worker is eligible to receive during their recovery period. Accurate and complete reporting on this form ensures that workers are fairly compensated in accordance with their usual earnings prior to the injury or illness.

What should I do if the injured employee has worked for less than 52 weeks?

If the injured worker has not been employed for the full 52 weeks before the injury, wage information should be provided for the actual period of employment. For the remaining weeks, wages of a fellow employee in the same class of employment who has worked for a year or more must be substituted. This ensures an equitable calculation of the average weekly wage, even if the injured worker's employment period is short.

Where can I find help if I have questions about completing Form 127?

If you have questions or need assistance with completing Form 127, you can contact the Massachusetts Department of Industrial Accidents through their Information Line at 800-323-3249 ext. 7470 if you're within Massachusetts. If you're outside Massachusetts, use 617-727-4900 ext. 7470. Additionally, visiting the Department's website or consulting with a legal professional specialized in workers' compensation can provide further guidance and support.

1. Not accurately reporting the worker's wages for the 52 weeks preceding the accident is a common mistake. The form requires detailed weekly wage information before taxes, and inaccuracies in this section can significantly affect the benefits calculation.
2. Another mistake is the failure to indicate whether the employee has been certified by the U.S. Veterans Administration for any disability. This detail is crucial as it may influence the compensation process.
3. People often overlook the section that asks whether room was furnished to the employee or if the employee earned tips or other benefits. Both of these contribute to the calculation of the average weekly wage and must be documented accurately.
4. Some individuals mistakenly leave out the name of a fellow employee when the injured worker has worked for less than 52 weeks. The instructions explicitly state to substitute wages of a fellow employee in the same class of employment for the remaining weeks, if applicable.
5. Forgetting to make comments or notes on the reverse side of the form or on a separate sheet can also be a faux pas. Often, there are unique circumstances or additional information that could affect the claim, and this section provides space to document such details.

In sum, attention to detail and thoroughness are key when completing the Massachusetts 127 form. Documenting accurate wage information, employment benefits, and any additional notes are critical elements to ensuring the form is filled out correctly and that the worker receives the appropriate compensation.

When dealing with workers' compensation claims in Massachusetts, using the Massachusetts 127 form for calculating an employee's average weekly wage is a key step. However, this form often requires additional documents to support the claim and ensure its accuracy. Understanding these documents can streamline the process, making it more understandable and less daunting.

• First Report of Injury (FROI-1): This form is the starting point for a workers' compensation claim. It documents the initial details of the employee's injury or illness, including when and how the injury occurred, the nature of the injury, and preliminary information about the employment and the injured employee. Employers or their insurers usually file this form to notify the Department of Industrial Accidents (DIA) of the incident.
• Wage and Salary Verification (Form 108): This document complements Form 127 by providing detailed information about the employee's earnings, including overtime, bonuses, and any other compensations received. It's essential for accurately determining the employee's average weekly wage, especially when the pay varies from week to week.
• Medical Reports: Medical evidence is crucial to support a workers' compensation claim. This includes initial medical reports following the injury, ongoing treatment records, and any permanent impairment evaluations. These reports not only corroborate the injury but also detail the extent of the injuries, the proposed treatment, and the anticipated time out of work.
• Employee Claim Form - Form 110: If there's a dispute regarding any aspect of the workers' compensation claim, the employee can file this form with the DIA to formally request benefits. This might include disputes over the extent of disability, the need for medical treatment, or the computation of the average weekly wage. The form outlines the employee's account of the injury, the nature of the dispute, and the specific benefits being sought.

Together with Form 127, these documents form the backbone of a workers' compensation claim in Massachusetts. They facilitate the accurate and efficient processing of claims, ensuring that injured workers receive the benefits they are entitled to in a timely manner. Each document plays a specific role in substantiating different aspects of the claim, from the initial report to the final determination of wages and benefits due.

The Massachusetts 127 form is similar to other state and federal forms used in the workplace for reporting and computing employee wages, especially in the context of accidents and disabilities. While each form has its unique applications and requirements based on jurisdiction and specific use cases, they share the common goal of documenting employment details, wage information, and other relevant data to ensure accurate reporting and computation.

One similar document is the Federal Wage and Tax Statement (Form W-2). It is used by employers to report wages, tips, and other compensation paid to employees, along with taxes withheld from their paychecks. While Form W-2 does not specifically relate to industrial accidents or disabilities, it is integral in verifying an employee's wage history, which can be necessary for completing the Massachusetts 127 form. Both forms require detailed employment and wage information but serve different regulatory and administrative purposes.

Another analogous document is the Worker's Compensation First Report of Injury or Illness (Form 101) used in Massachusetts. This form is vital for initiating a worker’s compensation claim when an employee gets injured or ill because of their job. Like the Massachusetts 127 form, it captures details about the employer, employee, and circumstances of the injury or illness. However, the Massachusetts 127 form focuses more specifically on computing the average weekly wage based on prior earnings, an essential figure in determining compensation benefits.

The Occupational Safety and Health Administration (OSHA) Form 300, which is a Log of Work-Related Injuries and Illnesses, also shares similarities with the Massachusetts 127 form. OSHA Form 300 is used by certain employers to record and summarize work-related injuries and illnesses. Comparatively, the Massachusetts 127 form collects detailed wage data to compute benefits following a workplace injury. While OSHA Form 300 is more about tracking the occurrence and nature of workplace injuries and illnesses for safety management purposes, both it and the Massachusetts 127 form play roles in the broader context of workplace health and safety administration.

When completing the Massachusetts Form 127, it's crucial to provide accurate and comprehensive information to ensure the Average Weekly Wage Computation Schedule is correctly calculated. The following list includes essential dos and don'ts to aid in the completion of this form.

• Do ensure all information is legible, whether printed or typed, to prevent misunderstandings or processing delays.
• Do verify the accuracy of the employer’s name and address, and double-check the insurer’s case file number and DIA Board number if known, for consistency and to avoid any confusion.
• Do accurately list the number of dependent children and other dependents to ensure the computation of the Average Weekly Wage reflects all entitled considerations.
• Do provide precise dates related to the employee's injury, disability onset, and date of employment, as these dates play a critical role in determining eligibility and compensation amounts.
• Don't forget to answer the question regarding any disability certification by the U.S. Veterans Administration; this information may affect the calculation of benefits.
• Don’t estimate or guess when reporting wages. Accurately report all wages earned by the injured worker during the 52 weeks immediately preceding the accident, using actual payroll records.
• Don’t leave sections blank. If certain information is not applicable, such as room furnished or tips earned, clearly indicate this by writing “N/A” or “No” as appropriate to provide complete responses.
• Don’t hesitate to use the reverse side of the form or a separate sheet for any comments if the provided space is insufficient, ensuring all pertinent information is communicated.