When filing a claim against the Workers' Compensation Trust Fund pursuant to MGL 152, § 65(2)(e), please note that the more information provided by the claimant at the time the claim is filed, the more likely the Trust Fund will be able to, at a minimum, pay the claim without prejudice, at least until the date of the §10 conference. In order to assist the Trust Fund in the processing and investigation of the claim, please supply the following information:

1. EMPLOYER NAME - When submitting an Insurance Inquiry Form to the DIA Office of Insurance, please be sure to list the proper name of the employer. If the employer is a d/b/a, please list the legal name of the employer and the business name. If the employer is a corporation, LLC or LLP, please include the name or names of the principals, corporate officers, directors, partners or members, etc. This will assist the Office of Insurance in conducting its search for insurance coverage. Please also include this information on the Form 110 (Employee Claim).

2. EMPLOYER ADDRESS - Please be sure to provide the correct business and/or home address of the employer on both the Insurance Inquiry Form and the Form 110.

3. ACCIDENT LOCATION/JOB SITE - Please list the correct address of both the location of the job site and the place of injury (if different from the job site). If the injury occurred at a private residence, include the name of the homeowners and any available information on the relationship between the homeowner and the employer. 

4. WITNESSES - Please include the names, addresses and phone numbers of any witnesses present at the time that the injury took place including any eyewitness to the incidents which caused the injury..

5. CO-WORKERS - Please include statements from co-workers or others on the job site who may have witnessed the event that caused the injury. Also include any relevant information concerning the facts of the case, such as the employer-employee relationship or wages. Helpful information includes statements from co-workers regarding who employed the employees, who directed their work, who was in charge of the job site, who provided the tools, how much they were paid and how they were paid.

6. GENERAL CONTRACTORS/SUB-CONTRACTORS AND OTHERS - Please list the names of all individuals on the job site and include any information available, such as addresses, phone numbers and relationship to the employer. If there were other businesses on the site, list the name of each business. Please include any potential general or sub-contractors any of the work.

7. WAGES - Please include any information which can corroborate wages paid to the claimant (i.e. copies of checks or statements of co-workers.)

8. PERMITS/CERTIFICATES - Please include any other information obtained such as building permits, business certificates filed with the city or town.

9. MEDICAL PROVIDERS - Please include the names, contact information and dates of treatment for all medical providers who have treated the claimant for the industrial accident.