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Massachusetts Employee Earning Report (Form 126)
SKU: FFMA205 |   E-mail this product to a friend
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Product Description

This form is used by the insurance company to request information from the injured employee. The employee must report to the insurer all earnings, including wages or salary from self-employment for the 26 weeks indicated on the form.

This form is sent just to the insurer. A copy is not sent to the DIA. If you have any questions regarding this form, please contact the workers' compensation insurance carrier!
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