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The Commonwealth of Massachusetts Department of Industrial Accidents Department 130 FORM 130 1 Congress Street, Suite100, Boston Massachusetts 021142017 Info. Line 8003233249 ext. 7470 in Mass. Outside

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How to fill out form b130b - massgov

How to fill out form B130B - Massgov:

01

Start by obtaining the form. Form B130B is used in Massachusetts for filing a request for a private plan workers' compensation insurer to approve a settlement for a recommencement of payments after a discontinuance of benefits.

02

Make sure to read the instructions carefully. The instructions will guide you through the process of filling out the form accurately and completely.

03

Fill out the claimant information. This includes the claimant's name, address, social security number, and contact information.

04

Provide the insurer information. This includes the name of the workers' compensation insurer, policy number, and contact information.

05

Indicate the claimant's attorney information, if applicable. Include the attorney's name, address, and contact information.

06

Fill out the employer information. This includes the employer's name, address, and contact information.

07

Specify the reason for discontinuance and the requested recommencement of payments. Provide a detailed explanation of why benefit payments were discontinued and the desired date for recommencement.

08

Attach any supporting documentation. If there are any additional documents that support the request, such as medical records or correspondence, make sure to include them with the form.

09

Sign and date the form. The claimant or their representative must sign and date the form to certify the information provided is accurate and complete.

10

Keep a copy for your records. It's essential to keep a copy of the completed form and any attached documents for future reference.

Who needs form B130B - Massgov:

01

Claimants who have had their workers' compensation benefits discontinued and wish to request a recommencement of payments from a private plan insurer in Massachusetts.

02

Attorneys representing claimants in workers' compensation cases involving a discontinuance of benefits and subsequent request for recommencement of payments from a private plan insurer in Massachusetts.

03

Employers who are required to fill out the form on behalf of their employees when discontinuing workers' compensation benefits and seeking recommencement of payments from a private plan insurer in Massachusetts.

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What is form b130b - massgov?

Form b130b is a document used by businesses in Massachusetts to report their annual financial information to the state government.

Who is required to file form b130b - massgov?

All businesses operating in Massachusetts are required to file form b130b with the state government.

How to fill out form b130b - massgov?

Form b130b can be filled out online through the state government's website or submitted via mail with the required financial information.

What is the purpose of form b130b - massgov?

The purpose of form b130b is to provide the state government with accurate financial information regarding businesses operating in Massachusetts.

What information must be reported on form b130b - massgov?

Form b130b requires businesses to report their annual revenue, expenses, profits, and other financial details.

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