This form is to be filled out only if the injured worker is filing a claim against the Workers' Compensation Trust Fund.
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. 491.
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. 491.
Download the Affidavit of Employee in Application for Trust Fund Benefits 