This form is to be filled out only if the injured worker is filing a claim against the Workers' Compensation Trust Fund.

Forward the completed form to:


                                    Workers' Compensation Trust Fund
                                    Department of Industrial Accidents
                                   1 Congress St., Suite 100
                                   Boston, MA 02114-2017

If you have any questions about this form, please contact the Trust Fund, 617-727-4900, ext. 7491.

Form 170 pdf format of form-170.pdf