Fill and Sign the Insurer Notification of Termination for Workers Compensation Massachusetts Form

YesNo Yes No - If Yes - Date Received (mm/dd/yyyy): Yes No (If Yes - 7 days written notice not required)      MODIFICATION                                                                                                                   Employee's Income $       No Personal Injury No Injury Arising Out of and in the Course of Employment No Disability                   No Causal Relationship Between Personal Injury and Disability Lack of Jurisdiction Lack of Notice Late Claim Other (Specify)                                           $             Modified Rate(s):                         FORM 106 The Commonwealth of Massachusetts Department of Industrial Accidents - Department 106600 Washington Street - 7th Floor, Boston, Massachusetts 02111 Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 DIA Board # (If Known): http://www.state.ma.us/diaINSURER'S NOTIFICATION OF TERMINATION OR MODIFICATION OF WEEKLY COMPENSATION DURING PAYMENT WITHOUT PREJUDICE PERIOD CHECK ONE BOX: TERMINATION FILE ONLY WHEN PAYMENT HAS BEEN MADE WITHIN 14 DAYS. AT LEAST 7 DAYS WRITTEN NOTICE MUST BE GIVEN TO EMPLOYEE OF THE INTENT TO STOP PAYMENTS, UNLESS BASED ON ACTUAL INCOME OF EMPLOYEE 1. Insurance Carrier's Name and Address: 2. Self-insured?:If Yes Please Give Self-insurer Number: I N S U R E R 3. Name & Address of Insurer's Attorney: 4. Telephone Number of Insurer's Attorney: 5. Claim Representative's Name: 6. Claim Representative's Tel. Number & Ext.: - 7. Insurer's Case File Number: 8. Did Insurer Receive First Report of Injury (Form 101); 9. Employee's Name (Last, First, MI): 10. Employee's Social Security Number*: 11. Employee's Address (No. and Street, City, State, Zip Code): 12. Date of Birth (mm/dd/yyyy): E M P L O Y E E 13. Date of Injury (nun/dd/yyyy): 14. First Day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy): 15. Fifth Day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy): 16. Employer's Name & Address (No. and Street, City, State, Zip Code): 17. Employer's Federal Tax ID #- 18. Employee Returned to Work:If Yes - Date of Return (mm/dd/yyyy): 19. Specify grounds for termination and give a brief statement of the specific facts supporting the grounds for termination. Failure to do so may cause loss of defenses under M.G.L. c 152, Sections 7(l) and 7(2). A. B. C. D. G. G R O U N D S X. Y. H. Use additional space on back of form if needed. 20. Last Date Through Which Payment Will Be Made (mm/dd/yyyy): 21. Date of Notification of Termination or Modification to theEmployee (mm/dd/yyyy): compensation paid and the Modification rate(s) of weekly compensation. 22. If this is a Modification rather than a Termination, please state the grounds and factual basis for the Modification and the prior rate(s) of weekly Basis for Modification (use reverse side if needed). Prior Rate(s): $ $ $ 23. Insurer's Signature: 24. Date Prepared (mm/dd/yyyy): *Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents. Please Print Clearly or Type. Unreadable forms will be returned. Form 106 - Revised 8/2001 - Reproduce as needed.      Explanation of Box 19 or Box 22 continued: