Requests from insurers for DIB payment information are received on form CR-28. Requests from companies located in Massachusetts are normally handled by the FO that services the insurer. Insurers located outside the State send their requests to SSA, attn: WC Unit, 10 Causeway Street, Room 148, Boston, MA 02222-1213

Receipt of a CR-28 indicates the worker is receiving WC. Before completing the form, check the MBR and WC/PDB ICF Datasheet to verify that we have WC information and that it’s current. Adjust offset if necessary and then complete the form.

SSA FOs are responsible for completing Part III.

1. a. 

   Block A – Check this if there is partial WC offset to at least one beneficiary.

2. b. 

   Block B - Check this if there is no offset because the worker attained age 62/65 or DIB terminated. Enter the appropriate month and year.

   NOTE: Effective December 19, 2015 or later, WC offset termination extends from age 65 to full retirement age (FRA). See 2015 amendment in DI 52101.005.

3. c. 

   Block C - Check this if an MBR “NIF” reply is received.

4. d. 

   Block D - Check this if the worker is receiving Social Security benefits other than DIB, or if the DIB claim was denied.

5. e. 

   Block E - Check this if blocks A, B, C, or D do not apply, and enter the requested data.

   • •

     ITEM 1 - Enter the total family benefit (TFB) as of the first possible month of offset using the current family configuration.

   • •

     ITEM 2 - Enter the 80 percent average current earnings (ACE) even if the TFB is the applicable limit. Furnish the 80 percent ACE based on the information on the MBR or WC/PDB ICF. Do not develop earnings to establish a potentially higher ACE solely for the data form.

     Complete items 3, 4 and 5 only if a triennial redetermination gave an increase in benefits.

   • •

     ITEM 3 - Enter the most recent 80 percent redetermined ACE.

   • •

     ITEM 4 - Self-explanatory.

   • •

     ITEM 5 - Enter the amounts payable to the family in the month of the redetermination (item 4), but before the redetermination increase.

6. f. 

   Block F - the FO must complete this block.

Scan a copy of the dated form into NDRED. Return the form to the State (or its carrier) at the address provided. The consent of the worker is not needed for SSA purposes as long as the information provided is used to administer the State WC program.

The attorney fee may be paid by the carrier or the worker.

• •

  When the carrier contests the award of periodic payments, the carrier is responsible for payment of attorney fees. However, the carrier is permitted to reduce the claimant’s WC, as credit towards the attorney fee, for one month only by up to 22 percent of that month's periodic benefits. Subsequent payments then will resume at the full rate. In these cases, the claimant may receive an "Order of payments" from the DIA showing "the insurer may withhold the employee's share of the attorney fees". The carrier's payment record may show the reduced rate for the one month with a comment "less Section 13(10)A". THIS COMMENT INDICATES THE EXCLUDABLE EXPENSE WAS DEDUCTED.

• •

  When the employee appeals a decision of an administrative judge and prevails, the employee must pay the attorney fees. These can be treated like any other excludable expense.

The attorney fee is paid from the amount of the settlement. For LS settlements, the fee is limited to 20 percent of the total lump sum amount if the insurer has accepted or been assigned liability. If the insurer has not accepted nor been assigned liability, then the fee is 15 percent of the total amount. The fee is lower if a LS includes Section 36 (scheduled award) payments, as attorneys cannot collect a fee on those benefits.

Department of Industrial Accidents

1 Congress Street, Suite 100

Boston, MA 02114-2017

Phone: 617-727-4900; 1-800-323-3249

TDD: 1-800-224-6196

If the carrier is unknown, call the Office of Insurance in Boston at 617-626-5481. They can tell you who the carrier is.

This is filed by insurance carriers when weekly benefits are paid within 14 calendar days of their receipt of a written claim for weekly benefits. It’s mailed to the Department of Industrial Accidents (DIA) with a copy to the worker and the Employer.

This is filed by insurance carriers within 14 calendar days of their receipt of a written claim for weekly benefits that is being denied. It can only be filed online via the DIA Case Management System(CMS).

This form is used to increase the period of voluntary payment by the insurer (the “Pay Without Prejudice” period) up to one year, with the worker’s written consent. The DIA must approve the form. It is filed the WC Board when compensation is initiated, reduced, modified or discontinued based on an agreement of the parties outside the litigation process.

When WC payments were made voluntarily, this form is filed to give advance notice to the worker of the carrier’s intent to stop or modify their WC. At least 7 calendar days written notice must be given to the worker unless the action is based on their actual income.

This is used as a notice to terminate or modify weekly WC payments, outside the pay without prejudice period.

When the worker’s claim was denied (or WC was reduced or stopped by the carrier) this form is filed by the worker to request a judicial proceeding before a judge.

All cases involving payment for Section 36 injuries (Specific injuries) must be reported to the DIA using this form.

Effective 12/24/1991 on, in most cases an employer must approve lump sum proposals. If the employer has approval authority and does not agree to approve the lump sum, then the proposal does not proceed. This form must be filed at the lump sum conference.

These forms are used for lump sum settlements. Form 117 is used for injuries on or after 11/01/1986 and Form 117a is used for injuries before 11/01/1986.