This government document is issued by Department of Industrial Accidents (DIA) for use in Massachusetts
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https://www.mass.gov/doc/form-105-agreement-to-extend-180-day-payment-without-prejudice-period/download?_gl=1*1w5f0kb*_ga*MjAwMDMyNzUzNi4xNzQ3MzExNzg5*_ga_MCLPEGW7WM*czE3NTEyODM1MTckbzY1JGcxJHQxNzUxMjg1MDkxJGo1MiRsMCRoMA..&_ga=2.45281250.732576894.1751258635-2000327536.1747311789