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  2. Workers' Compensation

Complete Form List (numbered)

  • Form 46A - Request For Section 46A Conference in Conjunction With Lump Sum Under Section 48

    Updated 3/2011

  • Form 101 - Employer's First Report of Injury/Fatality

    Updated 7/2010

  • Form 103 - Insurer's Notification of Payment

    Updated 7/2010

  • Form 104 - Insurer's Notification of Denial

    Updated 7/2010

  • Form 105 - Agreement to Extend 180 Day Payment-Without-Prejudice Period

    Updated 7/2010

  • Form 106 - Insurer's Notification of Termination or Modification of Weekly Compensation During Payment-Without-Prejudice Period

    Updated 7/2010

  • Form 107 - Insurer's Notification of Acceptance, Resumption, Termination or Modification of Weekly Compensation

    Updated 7/2010

  • Form 108 - Insurer's Complaint for Modification, Discontinuance or Recoupment of Compensation

    Updated 7/2010

  • Form 109 - Notification of Withdrawal of Claim or Complaint

    Updated 7/2010

  • Form 110 - Employee Claim

    Updated 7/2010

  • Form 112 - Appeal to Reviewing Board

    Updated 7/2010

  • Form 112A - Affidavit in Support of Request for Waiver of Filing Fee Under Section 11C

    Updated 7/2010

  • Form 113 - Agreement to Pay Compensation

    Updated 7/2010

  • Form 114 - Notice of Change/Appearance of Counsel

    Updated 7/2010

  • Form 115 - Third Party Claim/Notice of Lien

    Updated 7/2010

  • Form 116 - Request for Lump Sum Conference

    Updated 7/2010

  • Form 116A - Employer Consent to Lump Sum Agreement

    Updated 7/2010

  • Form 116B - Addendum to Lump Sum Agreement: Vocational Rehabilitation Status

    Updated 7/2010

  • Form 116C - Lien Disclosure Form

    Updated 7/2010

  • Form 117 - Agreement for Redeeming Liability by Lump Sum for Injuries On or After Nov. 1, 1986

    Updated 7/2010

  • Form 117A - Agreement for Redeeming Liability by Lump Sum for Injuries Before Nov. 1, 1986

    Updated 7/2010

  • Form 118 - Medical-Only - The DIA no longer supplies this form.

    The DIA no longer supplies this form. For a medical-only claim you would use whatever form your insurance carrier suplies to you. This form is NOT sent to the DIA.

  • Form 121 - Appeal of Conference Order

    Updated 7/2010

  • Form 121A - Agreement That No Impartial Physician Report is Required

    Updated 7/2010

  • Form 122 and Form 123 - Request for Sections 37/37A Proceedings/Agreement Forms

    Form 122 Updated 7/2010
    Form 123 Updated 7/2010

  • Form 124A - Notification of Arbitration Award

    Updated 7/2010

  • Form 125 - Motion for Expedited Conference

    Updated 7/2010

  • Form 126 - Employee Earning Report

    Updated 7/2010

  • Form 127 - Average Weekly Wage Computation Schedule


  • Form 130 - Complaint of Improper Claims Handling Against an Insurer

    Updated 7/2010

  • Form 131 - Request For Speedy Conference Because Of Hardship

    Updated 1/2012

  • Form 132 - Affidavit in Support of Employee's Request for Speedy Conference Because of Hardship

    Updated 7/2010

  • Form 133A - Utilization Review (UR) Agent Complaint

    Updated 10/2010

  • Form 134 - Health Care Provider Complaint

    Updated 7/2001

  • Form 136 - Affidavit of Indigence and Request for Waiver of Sec. 11A(2) Fees

    Updated 7/2010

  • Form 140 - Temporary Conference Memorandum Cover Sheet

    Updated 7/2010

  • Form 141 - Last Best Offer at Conference

    Updated 7/2010

  • Form 151 - Individual Written Rehabilitation Program Form

    Updated 12/20/2011.

  • Form 152 - Amendment/Suspension or Closure of Vocational Rehabilitation Plan

    Updated 12/20/2011

  • Form 153 - Affidavit of Exemption for Certain Corporate Officers or Directors

    Updated 7/2010

  • Form 154 - Verification of Massachusetts Workers' Compensation Coverage for Out-Of-State Employers Operating in Massachusetts

    10/28/2010

  • Form 160 - Employee's Biographical Data Sheet

    Updated 7/2010

  • Form 161 - Employee's Hearing Memorandum

    Updated - 7/2010

  • Form 162 - Insurer's Hearing Memorandum

    Updated 7/2010

  • Form 170 - Affidavit of Employee in Application for Trust Fund Benefits

    Updated - 7/2010


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