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Report a claim for Massachusetts

EMPLOYER'S FIRST REPORT OF INJURY OR FATALITY

Fields marked with an asterisk (*) are required—you cannot submit the form unless these fields are completed.

 
4. Gender*
6. Marital status*
18. Self-Insured?
21. Was Employee Injured on Employer's Premises?*
25. If Employee has Died, Date of Death (mm/dd/yyyy)*
31. Injury Code(s) Body Part Code(s)
33. Has Employee Returned to Work?*
36. Has Employee Returned to Regular Occupation?
40. The employee will be out of work for 5 or more calendar days

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