The procedure for filing a § 65 claim is as follows:

  • Obtain a Certificate of No Insurance.
  • Download the Employee Claim Form 110 from this website and fill it out. You will also find instructions on how to fill out this form.
  • Download the Affidavit of Employee In Application For Trust Fund Benefits Form 170 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