Town of Princeton

Step 2 - Medical Only Claim Form

Claims for injuries that result in medical bills, but fewer than five days of disability, are reported only to the Town’s workers’ compensation insurance company, and not to the Department of Industrial Accidents. The Medical Only Claim Form (see Appendix) should immediately be submitted to the Town Administrator who will in turn notify the Town’s insurance company within 24 hours of receipt.

The Town of Princeton maintains its workers’ compensation insurance with the Massachusetts Education and Government Association (MEGA). Once an employee has completed the Medical Only Claim Form, it should be turned into the Town Administrator who will forward the information to the MEGA Adjustor. The MEGA Adjustor will then contact the employee and physician to obtain further details and to instruct the parties on medical payment processing.

Step 3 - Disability Form 101

An injured worker becomes eligible for weekly compensation indemnity benefits when he/she has been totally or partially disabled due to an injury or occupational illness, and is incapable of earning full wages for five or more calendar days (the days do not have to be consecutive; disability can be total or partial). When this happens, the employer is required to file the Form 101, Employer’s First Report of Injury/Illness/Death, in compliance with MGL C. 152 86 (see Appendix) with the Town Administrator.

This form must be submitted to the Department of Industrial Accidents, the insurance carrier and the employee within seven days from the fifth day the employee has been disabled because of the accident. The original signature is required on the form sent to the DIA.

It is the responsibility of the employer to report the disability, whether or not the employer agrees with the employee’s claim or not. The form is not an admission of liability.

Form 101 should be immediately distributed as follows:

Distribute a copy of Form 101 to the employee.

Distribute a copy of Form 101 to the Town’s insurance company.

File a copy of Form 101 in the Town’s employee records.

Step 4 – Payment of Claim

Once the insurer receives the Form 101, the company/agency has 14 days to pay benefits or notify the employee and the DIA that they are contesting the claim. The insurance