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Fill in a Valid Massachusetts 127 Form

The Massachusetts 127 form is a document used to calculate the average weekly wage for employees who have sustained work-related injuries. This form is essential for ensuring that injured workers receive the appropriate compensation based on their earnings prior to the incident. Proper completion of the form helps streamline the claims process and supports fair treatment for all parties involved.

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Article Structure

The Massachusetts 127 form plays a crucial role in the workers' compensation process, specifically for calculating an injured employee's average weekly wage. This form is utilized by the Department of Industrial Accidents and is essential for ensuring that employees receive fair compensation for lost wages due to work-related injuries. Key elements of the form include the employer's and employee's information, the dates of injury and disability, and the number of dependents. It requires a detailed account of the wages earned by the employee during the 52 weeks preceding the injury, with provisions for those who have worked for less than a year. Additionally, the form addresses whether any room or tips were provided to the employee, which can impact the overall wage calculation. Accurate completion of the Massachusetts 127 form is vital, as it directly influences the compensation benefits an injured worker may receive. Timeliness and precision in filing this form cannot be overstated, as delays or inaccuracies could result in significant financial hardship for the employee during their recovery period.

Massachusetts 127 Example

	FORM 127	The Commonwealth of Massachusetts
	FORM 127	Department of Industrial Accidents
		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

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:				Year:			Year:
11.	Year:				Year:			Year:
Week	Week Ending		Gross Amount	Week	Week Ending	Gross Amount	Week	Week Ending		Gross Amount
Week	Week Ending		Before Taxes	Week	Week Ending	Before Taxes	Week	Week Ending		Before Taxes
No.	Month	Day		No.	Month Day		No.	Month	Day
	Month	Day			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				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:

Download Massachusetts 127 PDF Form

Form Specs

Fact Name	Description
Purpose	The Massachusetts 127 form is used to calculate the average weekly wage for employees who have suffered a workplace injury.
Governing Law	This form is governed by Massachusetts General Laws Chapter 152, which pertains to workers' compensation.
Submission Requirements	Employers must complete the form with accurate wage information from the 52 weeks prior to the injury.
Dependent Information	The form requires information on the number of dependent children and other dependents of the injured employee.
Certification	It includes a question about whether the employee has been certified by the U.S. Veterans Administration for any type of disability.
Fellow Employee Wages	If the injured employee worked less than 52 weeks, wages of a fellow employee in the same job class may be used.
Signature Requirement	The form must be signed by the employer or preparer to certify the accuracy of the information provided.

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