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The Agreement to Extend Payment Without Prejudice Period Form & Why Not to Sign It

After an Employee is injured on the job, their day to day lives are often thrown into a tailspin. As if being injured and unable to work isn’t stressful enough, most employees are left with the burden of figuring out their finances, attending doctor’s appointments, and being buried in paperwork. Often times, employees rely on and trust their adjusters to help them get through this tough period; unfortunately, adjusters and insurance companies are usually more interested in protecting their own interests. During this difficult time, most employees will receive a Form 105, “Agreement to Extend Payment Without Prejudice Period” in the mail. This form will also be accompanied with a letter that indicates that the employee has been “approved” or “could be paid for up to a year” if they sign the form. This letter is meant to mislead the employee and make them feel as if the form is in the employee’s best interest. It’s not.

Signing the Agreement to Extend 180 Day Payment Without Prejudice Period form can have an extremely negative impact on an employee’s claim. At first glance, the form seems harmless and possibly beneficial to the employee; however, by signing this form, the employee is giving up his or her legal rights — and it may allow the insurer to legally terminate benefits. It may also put the employee in a position where they could go months without benefits while waiting for a court date.

In every case, during the first 180 days from the first date of disability, the insurer is allowed to stop payments to the employee without obtaining approval of the Department of Industrial Accidents or the consent of the employee. The insurer is required to give the employee seven days written notice of the termination benefits.

Once an employee has been paid for 180 days, it becomes much more difficult for the insurer to stop benefits. In most cases, the insurance company would need to file a complaint with the Department of Industrial Accidents.

By signing the agreement, an employee is allowing the insurance company another 6 months to have the right to terminate benefits for any reason so long as they provide you with seven days notice.

If you or someone you know has received a Form 105 (Agreement to Extend Payment Without Prejudice Period), please contact Keches Law Group at 617-898-0808 to discuss your rights today.


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