• You must complete and send an Employee's Claim - Form 110 to the DIA. It is important that you fill out this form completely and accurately. Forms are available on this website and at any Department of Industrial Accidents (DIA) office. Do not send this form to the DIA unless you have received an Insurer's Notification of Denial - Form 104, or it's been 30 or more calendar days from your injury or illness date, and you have not heard from the insurer.
  • You need to attach copies of any medical evidence that supports your claim, including medical bills and medical reports (not actual x-rays, MRI's, etc.) that document how your injury or illness is related to your work. Once you complete the claim form, attach the required documents and submit the claim package to the DIA at the address printed on the top of this form.
  • You must also send a copy of the completed Employee's Claim - Form 110 to the insurer. We recommend that you keep a copy of this form for your own files.
  • Once the DIA receives your completed Employee's Claim - Form 110, you will be scheduled for a Conciliation within two weeks or so. This will start the dispute process. You will be notified in writing of the date, time and location of this meeting.
  • Please Note: When you come to any DIA office for a proceeding, be sure to bring with you any letters the insurer or the DIA has sent to you, along with any other relevant paperwork, especially the letter telling you to come to the DIA .

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