File a workers' compensation claim against the Workers' Compensation Trust Fund (WCTF)

Find out how to file a claim with the Department of Industrial Accidents (DIA) if your employer does not have workers’ compensation insurance.
You should get a notice within 1 – 2 weeks after submitting your claim.

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The Details of File a workers' compensation claim against the Workers' Compensation Trust Fund (WCTF)

What you need for File a workers' compensation claim against the Workers' Compensation Trust Fund (WCTF)

To file a workers’ compensation claim with the Department of Industrial Accidents (DIA) against the Workers’ Compensation Trust Fund (WCTF) you will need to know:

  • Your date of injury, illness, or death if a dependent is filing fore benefits
  • The 1st calendar day of work you missed
  • The 5th calendar day of work you missed
  • The body parts and types of injuries
  • What type of benefits you are looking for
  • How long you may be out of work, if known
  • Where you first went for treatment
  • Your current treating doctor

If you file a claim seeking weekly compensation benefits, you're required to attach a copy of a doctor's report or record not more than 6 months old that describes the extent and length of time of your physical or emotional incapacity for work. This report must also relate your incapacity to your claimed industrial injury.

You are also required to attach a Certificate of No Insurance and DIA Form 170 - Affidavit of Employee in Application for Trust Fund Benefits.

How to file File a workers' compensation claim against the Workers' Compensation Trust Fund (WCTF)

To file a claim against the WCTF, you will need to file 3 documents and any supporting documentation as required:

To verify that your employer has no workers’ compensation insurance.

  1. Download and complete the Form 110 – Employee Claim. List the Workers’ Compensation Trust Fund as the insurer. Attach a copy of your physician's report or record to the Form 110.
  2. Download and fill out the Form 170 – Affidavit of Employee in Application for Trust Fund Benefits.
  3. Download and fill out an Insurer Request Certification Form. Mail the form to

                         Tom Finneran
                         Office of Insurance
                         Department of Industrial Accidents
                         19 Staniford St., 5th Floor
                         Boston, MA 02114

This form verifies that your employer has no workers' compensation insurance coverage. The Office of Insurance will send you a certified letter called a Certification of No Insurance.

Include the original certified letter when you file the Form 110 – Employee Claim.

You will need 3 copies of all the forms and documents

  • 1 copy for the DIA
  • 1 copy for the Workers’ Compensation Trust Fund
  • 1 copy for your records, or in case you hire an attorney later

Send your signed Form 110 – Employee Claim with copies of your supporting documents, Certification of No Insurance, and Form 170 - Affidavit of Employee in Application for Trust Fund Benefits to:

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

Also send a  copy by certified mail to:

                     Workers’ Compensation Trust Fund
                     c/o Department Industrial Accidents
                     1 Congress St., Suite 100
                     Boston, MA 02114

Submit your original copy of Form 110 – Employee Claim with copies of your supporting documents, original Certification of No Insurance, and Form 170 - Affidavit of Employee in Application for Trust Fund Benefits in person at the DIA office:

                       Department Industrial Accidents
                       1 Congress St., Suite 100
                       Boston, MA 02114

Next steps for File a workers' compensation claim against the Workers' Compensation Trust Fund (WCTF)

Notification and investigations

You will be contacted by a claims representative and an investigator from the DIA to discuss your claim.

You will receive a notice from the DIA regarding a conciliation for your claim. A conciliation is the first step in the dispute process. 

Contact for File a workers' compensation claim against the Workers' Compensation Trust Fund (WCTF)

Address
Boston DIA
1 Congress St., Suite 100, Boston, MA 02114

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