Box #1 - Please print or type your full last name, first name and middle initial.
Box #2 - Entering your nine (9) digit social security number, is purely voluntary, but will be helpful to the DIA in keeping your records separate from others with the same name.
Box #3 - Please print or type your home telephone number.
Box #5 - Please print or type your number of dependents.
Box #6 - Please print or type your FULL home address. This is important because ALL notices, orders and decisions regarding your case will be sent to this address.
Box #7 - If you wish, you may provide your e-mail address to us, but you will receive notices through the regular postal service.
Box #7a - Please indicate your native language using the NATIVE LANGUAGE CODES on the back of the form.
Box #10 - Please print or type your employer's business name and address. If your company has more than one address, use the address of their business office.
Box #10a - Please try to determine from the INDUSTRY CODES on the back of the form your employer's type of business. If you CANNOT, just print or type number 99.
Box #11 - Please print or type your employer's workers' compensation insurance company. (NOT the insurance agent, but the name of the carrier that will be paying benefits to you.) We cannot schedule a Conciliation without this information. If your employer will not tell you the name of the insurer, call our office of insurance, 727-4900, x 405.
Box #12 - Please print or type the date that you believe that you were originally hurt on the job or became ill because of a work-related illness. Use the date you first got medical treatment, or the last day you worked if you are unsure of the exact date.
Box #12a - Please print or type the case number/claim number that your employer's workers' compensation insurance company assigned your claim.
Box #13 - Please print or type the first day that you were incapable of earning full wages because of your injury or illness.
Box #14 - Please print or type the fifth day that you were incapable of earning full wages because of your injury or illness. This day does not have to be the fifth consecutive calendar from the first day of disability (Box #13).
Box #17a - Please print or type the nature of your injury or illness and the body part that has been affected by your injury or illness, from the codes printed on the back of the form. You may have more than one injury or illness listed (e.g. - a. 300, b. 310, c. 210), but the type of injury or illness listed in a MUST match the body part listed in a, and so on.
Box #23 - Please check the benefits that you are claiming are due to you under the law. Other sections of the law include § 30 - medical bills; § 28 - willful misconduct of employer, and § 7 - penalties and interest for late payments.
Box #26 - Please sign this form.
Box #27 - Please date this form.
Box #28 - If you have an attorney, they may sign here, otherwise leave this box blank.
WHAT TO DO WITH THIS CLAIM FORM
Department of Industrial Accidents - Dept. 110One (1) copy should be mailed to the insurance carrier, and you should keep one (1) copy for your records. You can send a copy to your employer, but you are not required to send them a copy unless you are filing for double compensation under § 28 (Willful Misconduct). You must also attach documentation as required by 452 CMR 1.07
1 Congress Street - Suite 100
Boston, MA 02114-2017
NOTE: An attorney filing this form must send a copy to the insurer by certified mail in order to be entitled to an attorney's fee. MGL c. 152, § 10 (1).
When the DIA receives your form a Conciliation will be scheduled for you within a few weeks. This session will be held in the department office closest to the employee's home.
Best wishes for a prompt and full recovery.