The Employee Claim Form - Form 110 should be completed whenever you think you are not getting the workers' compensation benefits you are entitled to. For example, your company or its insurance company has said it will contest your right to receive compensation benefits OR it has reduced or stopped payment of your compensation for reasons that you do not believe are fair.

Documentation, as required by 452 CMR 1.07, must also be attached to the Employee Claim form. This documentation needs to be sent to the Department of Industrial Accidents (DIA) and the insurer.

If the claim is just for medical bills, you need to include copies of the bills to the DIA and the insurer.

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).

The ONLY reason for completing this form is to request a judicial proceeding before an Administrative Judge, in order to obtain workers' compensation benefits from your employer's insurance company (or the Workers' Compensation Trust Fund if the employer was breaking the law by not having insurance).