As of July, 2005, the following forms can be filed electronically:
To be able to file electronically, you must request a login and password.
- Form 101 FR -- Employer's First Report Of Injury/Illness
- Form 103 PC -- Insurer's Notification Of Payment
- Form 104 DC -- Insurer's Notification Of Denial
- Form 106 NM -- Insurer's Notification Of Modification of Weekly Compensation During Pay Without Prejudice Period
- Form 106 NT -- Insurer's Notification of Termination Of Weekly Compensation During Payment Without Prejudice Period
- Form 107 GT -- Insurer's Notification of General Termination Of Weekly Compensation
- Form 107 RC/NM -- Insurer's Notification Of Resumption Or Modification Of Weekly Compensation
- Form 108 D-- Insurer's Complaint For Modification, Discontinuance OR Recoupment Of Compensation
- Form 110 C -- Employee Claim Form
- Form 115 TPC -- Third Party Claim
- Form 115 TPL -- Third Party Notice of Lien
- Form 116 LSR -- Request For Lump Sum Conference
2. Are the Department of Industrial Accident's Numbered forms available on disk or electronically?
The DIA does not have forms on disk, however some insurance companies and large employers have developed forms using form-creating software. The director of the Office of Claims Administration has approved these forms for submission. The forms at present available on our web page are saved in a format that allows them to be downloaded and printed, but does not allow for the insertion of information onto them. The department hopes that some time in the future to have interactive forms available for filings.
3. I work as an adjuster for an insurer; is there a form we need to use to deny a claim on an injury prior to 1986?
No. A Form 104 or Form 106 would probably be rejected. To deny the claim you would just need to respond to the claim with a letter via certified mail.
4. We paid a claim without prejudice for a period, then terminated the benefits. The employee filed an employee claim (Form 110) to have the benefits reinstated. Do we need to file a denial of payment (Form 104)?
Yes. A Form 104 should be used to deny the claim.
5. I am an out of state-medical-provider; am I required to accept medical rates as established by the Massachusetts Rate Setting Commission when I treat clients under Mass Law?
The DIA Reviewing Board ruled on April 16, 1992, in the Tedeschi case, that out-of-state providers ARE bound by the rates set by the The Center for Health Analysis and Information (CHIA). In an accepted case, providers that believe they have received less than they are entitled to should file a third party lien (Form 115).
6. Does an insurer need to get the permission of the Department to suspend benefits under § 11D, for failure to appear at a medical exam?
There is no requirement that the insurer seek approval before suspending benefits. However, once the employee has met the conditions of the regulations, the insurer must pay full retroactive benefits to the employee.
7. I represent an insurer. We are paying benefits to an employee whom we feel is not cooperating with us in regards to vocational rehabilitation; How do we get the DIA's permission to reduce been fits?
Write to William Harney, Director, Office of Education and Vocational Rehabilitation, at our Boston office. Provide him with the employee's name and board number, and your justification for requesting a reduction in benefits. He will respond to your request.
8. How do we determine if there is a Cost-Of-Living Adjustment (COLA) offset for workers receiving Social Security Disability benefits and total and permanent WC benefits?
The Social Security Administration has provided guidance with a COLA DATA form.
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