FORM 101'S CAN ONLY BE FILED ONLINE 
VIA A DIA ONLINE ACCOUNT

Apply For A DIA Online Account  You will receive a log in and password within a few days of your request as well as instructions on use of the account and all features.

Login For Existing Electronic DIA Accounts

 

The Form 101 should be filled out when an employee is injured, or alleges an injury, and is unable to earn full wages for five or more calendar days (Mondays through Sundays). It is the responsibility of the employer to report an alleged injury, whether or not the employer agrees with the employee's claim or not.

This form must be filed within seven (7) calendar days (not counting Sundays and legal holidays), from the fifth day of disability.

Once you have completed the electronic Form 101, you should print out three (3) copies:

  • One for the employee
  • One for your insurance company.
  • One for your own records.