File this form with the Department of Industrial Accidents within 30 days from the filing date of the Hearing decision by an Administrative Judge. This form is NOT to be used to appeal a conference order; use the Form 121 for that.

For injuries occurring on or after November 1, 1986, this form must be accompanied with a fee of thirty (30) percent of state average weekly wage at the time of the appeal, unless the filing fee has been waived by the Reviewing Board due to indigency of the employee. (As of October 1, 2013, the fee is $ 354.38) Make check out to "Massachusetts Industrial Accidents Special Fund". There is no filing fee for injuries occurring prior to November 1, 1986.

Mail appeal, and fee to:

Department of Industrial Accidents
Reviewing Board Fee Processing
1 Congress Street, Suite 100
Boston, MA 02114-2017

Print Form 112 pdf format of Form 112.pdf