The procedure for filing a § 65 claim is as follows:
  • Apply for ad obtain a Certificate of No Insurance from the Department's Office of Insurance.
  • Download the Form 110 - Employee Claim from this website and fill it out. You will also find instructions on how to fill out this form.
  • Download the Form 170 - Affidavit of Employee in Application for Trust Fund Benefits and fill it out.
  • Attach the Certificate of No Insurance to the Affidavit of Employee In Application for Trust Fund Benefits Form 170 and the Employee Claim Form 110 and send all three documents to:

    Department of Industrial Accidents - Dept. 110
    1 Congress St., Suite 100
    Boston, MA 02114-2017