Massachusetts Required Postings and Forms
The adjusting of the claims in this state are handled by Broadspire. Once a claim is reported to EMPLOYERS, the report will be sent to Broadspire for assignment. The contact information for Broadspire is:
P.O. Box 14133
Lexington, KY 40512
Toll free: 800-258-9546
Please post the following notices, in English and other appropriate languages, in a conspicuous location frequented by employees such as the break room, lunch room or time clock. If you have multiple office locations be sure to post the notices at each location.
- Workers’ Compensation Notice to Employees Poster - You are required to provide your employees with notice of workers’ compensation coverage. You can obtain this Notice to Employees by visiting the Massachusetts Department of Industrial Accidents' website or calling them. This poster is available in English, Arabic, Cape Verdean, Chinese, Haitian Creole, Khmer, Portuguese, Spanish and Vietnamese.
- Anti-Fraud Notice (English and Spanish)
The following forms need to be completed and submitted to EMPLOYERS when a work-related injury occurs:
- The Employer’s First Report Of Injury/Fatality Form 101 (First Report of Injury) - This form must be filed electronically with the Department of Industrial Accidents (DIA) within seven calendar days (not including Sundays and legal holidays) from the fifth full or partial day of disability. Submission of the form does not constitute an admission of liability.
Once you have completed the electronic Form 101, you should print three copies: One (1) copy MUST be given to the employee; one (1) copy MUST be submitted to EMPLOYERS and keep one (1) copy for your records.
You must apply for a login and password with the DIA to create an account if you do not already have one. Accounts are provided free of charge.
- Employee Earning Report Form 126 - This form enables us to calculate the correct compensation that may be owed to your injured employee. The injured employee must complete the form and submit it to EMPLOYERS within five days after of any accident that has caused the employee to be disabled for more than three scheduled work days.
- Accident Investigation Report - This basic accident form should be completed by the employee’s supervisor/manager as soon as possible after the accident. Please send the report to the following EMPLOYERS address as soon as it has been completed by the supervisor/manager: EMPLOYERS Claims Department, P.O. Box 32036, Lakeland, FL 33802-2036. You should keep a copy on file for your records.
- First Fill Form. This form provides your employees with basic information about our Pharmacy Benefit Program, including such things as the phone number to call to locate a First Fill participating pharmacy. When your employee becomes injured, please print and complete this form and provide it to your injured employee. Your employee will need to provide this completed form along with the prescription for his/her work-related injury or illness to the pharmacist. Using this form will help enable quick authorization for your employee’s initial medication and ensure that the initial prescription is provided at no cost to the injured employee.
- Off-Site Transitional Duty Program - Helping Your Injured Employees Get Back to Work
A successful transition back to work relies on the collaborative efforts of the manager/supervisor, the injured employee and their adjuster. As a manager/supervisor, learn what you can do to help facilitate a successful return to work.