The Massachusetts 127 form is a crucial document used to calculate an employee's average weekly wage following a workplace injury. This form is essential for ensuring that injured workers receive the appropriate compensation based on their earnings prior to the accident. If you need to fill out this form, click the button below to get started.
The Massachusetts 127 form serves as a crucial tool in the workers' compensation process, specifically designed to compute the average weekly wage of an injured employee. This form is essential for employers and insurers alike, as it provides a standardized method for reporting wages earned by the employee during the 52 weeks leading up to the injury. It captures key information such as the employer's name, the employee's details, and the dates of injury and employment. Additionally, the form requires the number of dependents, which can influence the compensation calculations. It is important to accurately report wages, including any tips or benefits, and to substitute wages from a fellow employee if the injured worker has not been employed for a full year. This ensures that the compensation reflects the employee's true earning potential. Completing the form accurately is not just a matter of compliance; it directly impacts the financial support the injured worker will receive during their recovery. Employers must also provide a signature to validate the information, making the form a legally binding document in the workers' compensation claim process.
FORM 127
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
Info. Line 800 323-3249 ext. 7470 in Mass. Outside Mass. - 617-727-4900 ext. 7470
http://www.mass.gov/dia
AVERAGE WEEKLY WAGE COMPUTATION SCHEDULE
DIA USE ONLY
Print or Type
1. Employer’s Name and Address:
2.
Insurer’s Case File #:
3.
DIA Board # (if known):
4. Employee’s Name and Address:
5.
# of dependent children:
6.
# of other dependents:
7. Date of Injury (mm/dd/yyyy):
8. Date of Disability (mm/dd/yyyy):
9. Date of Employment (mm/dd/yyyy):
10. Has employee been certified by U.S. Veterans Administration for any type of disability?
Yes
No
Indicate only those wages earned by the injured worker during the 52 week period immediately preceding the accident. If the injured employee has worked for less than 52 weeks, report wages from the time worked and, for the remaining weeks on this schedule, substitute wages of a fellow employee in the same class of employment who has worked for one year or more.
11.
Year:
Week
Week Ending
Gross Amount
Before Taxes
No.
Month
Day
Month Day
1
19
37
2
20
38
3
21
39
4
22
40
5
23
41
6
24
42
7
25
43
8
26
44
9
27
45
10
28
46
11
29
47
12
30
48
13
31
49
14
32
50
15
33
51
16
34
52
17
35
Total:
18
36
12. Was room furnished to the employee?
Yes No
13. If tips or other benefits were earned, describe and state value per week:
THIS IS A TRUE COPY OF THE PAYROLL RECORD OF THE ABOVE NAMED EMPLOYEE OR FELLOW EMPLOYEE IN THE SAME CLASS OF EMPLOYEMENT
14. Name of Fellow Employee (if
15. Employer/Preparer Signature:
16. Date Signed (mm/dd/yyyy):
applicable):
Make any comments on the reverse side of this form or on a separate sheet.
Form 127 – Revised 87/2013
Reproduce as needed.
Comments:
Filling out the Massachusetts 127 form requires attention to detail and accuracy. This form collects information necessary for calculating average weekly wages, which is essential for workers' compensation claims. Follow the steps below to complete the form correctly.
Once you have completed the form, review it for accuracy before submission. Any comments can be made on the reverse side or on a separate sheet as needed.
The Massachusetts 127 Form is a document used to calculate the average weekly wage of an employee who has been injured on the job. It is primarily utilized by the Department of Industrial Accidents in Massachusetts to assess wage compensation for injured workers. The form collects information about the employer, employee, and details surrounding the injury.
This form must be completed by the employer of the injured worker. It is essential for employers who are filing for workers' compensation claims on behalf of their employees. The form is also important for those who have employees that have suffered work-related injuries and are seeking compensation for lost wages.
The form requires various pieces of information, including:
The average weekly wage is determined by adding the gross amounts earned by the employee during the 52 weeks before the injury. If the employee has worked for less than 52 weeks, wages from the time worked should be reported. For the remaining weeks, substitute wages from a fellow employee in the same job classification who has worked for a year or more. This ensures a fair calculation of the average wage.
If the injured employee has not been with the company for a full year, the employer should report the wages earned during the time the employee worked. For the weeks not worked, wages from a comparable employee in the same class of employment should be used. This approach helps maintain equity in wage calculations.
Inaccurate Employer Information: Providing incorrect details about the employer's name or address can lead to delays in processing. Always double-check this information for accuracy.
Missing Employee Details: Failing to fill out the employee's name and address completely can cause confusion. Ensure all sections are filled out clearly.
Incorrect Dates: Entering the wrong dates for injury, disability, or employment can lead to complications. Verify that all dates are correct and formatted properly (mm/dd/yyyy).
Omitting Dependent Information: Not listing the number of dependent children or other dependents can affect benefit calculations. Make sure to include this information accurately.
Failure to Report Accurate Wages: It's essential to only report wages earned during the 52 weeks before the accident. Substituting wages from a fellow employee must be done correctly, or it may result in incorrect calculations.
Neglecting to Indicate Room and Board: If the employee received room and board, this must be noted. Failing to do so can lead to incomplete wage calculations.
Missing Signatures: Not signing the form can render it invalid. Ensure that the employer or preparer signs and dates the form before submission.
The Massachusetts 127 form is essential for calculating the average weekly wage of an injured employee for workers' compensation purposes. Alongside this form, several other documents are often required to ensure a comprehensive claim process. Below is a list of forms that may be used in conjunction with the Massachusetts 127 form.
Utilizing these forms along with the Massachusetts 127 can help streamline the claims process and ensure that all parties have the necessary information for a fair resolution. It is important to complete each form accurately and promptly to avoid delays in receiving benefits.
The Massachusetts Form 126 is similar to the Form 127 in that it is used to compute the average weekly wage for employees. This form collects information about the injured worker’s earnings over a specified period, similar to the 52-week reporting period in Form 127. Both forms require detailed wage information, including gross amounts earned before taxes. The key difference lies in the specific use of Form 126 for workers’ compensation claims related to temporary total incapacity, while Form 127 is specifically for average weekly wage calculations.
The Massachusetts Form 110 is another document that shares similarities with Form 127. Like Form 127, Form 110 is used to report wage information for employees who have sustained injuries. Both forms aim to provide a clear picture of the employee's earnings, which is essential for determining compensation. However, Form 110 is typically used in cases where a claim is being filed for permanent and total disability, focusing on long-term wage assessments rather than average weekly wage calculations.
The Massachusetts Form 101 is also comparable to the Form 127. This form is utilized to report an employee's earnings and is often required in the context of workers’ compensation claims. Similar to Form 127, it collects data regarding wages earned during a specific timeframe. However, Form 101 is generally used for initial claims, while Form 127 is often used for ongoing wage calculations after a claim has been established.
The Massachusetts Form 130 serves a similar purpose to Form 127, as it is used to document wage information for employees who are injured. Both forms require the reporting of earnings over a specified period. The primary distinction is that Form 130 is often used for cases involving specific injury types or conditions, whereas Form 127 focuses more broadly on average weekly wages across various circumstances.
Finally, the Massachusetts Form 134 is akin to Form 127 in that it also involves wage calculations for workers' compensation claims. Both forms require employers to provide detailed wage information for the employee in question. However, Form 134 is typically used for reporting wage information related to specific types of benefits or compensation adjustments, while Form 127 is focused on establishing an average weekly wage for ongoing claims.
When filling out the Massachusetts 127 form, it is crucial to be thorough and accurate. Here are six important do's and don'ts to keep in mind:
Following these guidelines will help ensure that the form is completed correctly and processed without unnecessary delays. Accuracy is key to avoid complications in the claims process.
The Massachusetts 127 form is an essential document used for calculating an employee's average weekly wage in the context of workers' compensation claims. However, several misconceptions surround its purpose and use. Below are five common misconceptions:
This is inaccurate. The Massachusetts 127 form can be used for both full-time and part-time employees. If an employee has worked less than 52 weeks, the form allows for the inclusion of wages from a fellow employee in the same job classification who has worked longer.
Not every injury requires a Massachusetts 127 form. It is specifically used when determining average weekly wages for workers' compensation purposes. If the claim does not involve wage calculations, the form is unnecessary.
This is misleading. While employers typically complete the Massachusetts 127 form, employees can also provide input, especially regarding their wages and any benefits received. Collaboration can ensure accuracy.
This misconception overlooks the broader context of disability. The form is relevant not only for workplace injuries but also for disabilities that may arise from other causes, provided they affect the employee's ability to work.
While certain information is sensitive, the Massachusetts 127 form is often shared with relevant parties involved in the workers' compensation process, including insurers and legal representatives, to facilitate the claim.
When filling out the Massachusetts 127 form, it’s essential to pay close attention to detail. This form is used for calculating the average weekly wage for injured workers. Here are some key takeaways to ensure accuracy and compliance:
By following these guidelines, you can help ensure that the Massachusetts 127 form is completed correctly, which can facilitate a smoother process for obtaining benefits.