File a workers' compensation claim

Next steps   for File a workers' compensation claim

1. Get notification

   Once you have completed the form and have your attachments, you will need to make 3 copies:

   • Send a copy of the Form 110 – Employee Claim and all supporting documents to your employer’s workers’ compensation carrier by Certified Mail
      
     • You must attach copies of medical reports, bills, etc. to the form you send to the insurer even if you know they already have them. If these documents aren’t attached, the insurer’s attorney will ask the DIA to withdraw the claim because it wasn’t filed correctly.

   The DIA will review your claim and respond in 2 ways:

   • The DIA can reject the form for several reasons and send everything back to you. A rejection letter is attached to the form stating what information is missing or incorrect.
   • If the information is correct, we’ll send a notice to you, the insurance company, and your employer with a date, time and place to appear to meet a conciliator to discuss your claim. This informal meeting is called a conciliation.
      
     • Your employer gets a notice as a courtesy. They don’t need to appear unless the insurance company wants them to, or if they had no workers' compensation insurance on the date of your injury.

2. Information

   Most claims get rejected by the DIA because they have the incorrect insurance carrier, have not checked off the types of benefits they are looking for, or do not enter a 1st and 5th day of disability.

   If you don’t know the name of your employer’s insurance company, you can look on any of the insurer forms they send you, especially the Form 104 – Notification of Denial. You can also call our Office of Insurance for assistance at (617) 626-5480 or (617) 626-5481, or look up your employer's insurer online.

   If your employer doesn’t have workers' compensation insurance, you will need to file a claim against the Workers' Compensation Trust Fund, which is part of the DIA.