Alphabetical form list

All the Department of Industrial Accidents' (DIA) forms that we use.

Forms

Addendum to Lump Sum Agreement: Vocational Rehabilitation Status (Form 116B) (Updated 1/2015)

Affidavit for Builders, Contractors, Plumbers, and Electricians (Updated 2/23/2015)

Affidavit of Employee in Application for Trust Fund Benefits (Updated 7/2010)

Affidavit of Exemption for Certain Corporate Officers (Form 153) (Updated 7/2010)

Affidavits for General Businesses (Updated 2/23/2015)

Affidavit of Indigence and Request for Waiver of §11A(2) Fees (Form 136) (Updated 7/2013)

Affidavit in Support of Employee's Request for a Speedy Conference Because of Hardship (Form 132) (Updated 7/2013)

Affidavit in Support of Request for Waiver of Filing Fee Under §11C

Agreement to Extend 180 day Payment-Without-Prejudice (Form 105) (updated 2/2017)

Agreement That No Impartial Physician Report is Required (Form 121A)

Agreement to Pay Compensation (Form 113)

Amendment, Suspension or Closure of Vocational Rehabilitation Plan (Form 152)

Appeal of a Conference Order (Form 121)

Appeal to Reviewing Board (Form 112)

Application to Become an Approved Utilization Review Agent and Affidavit of Compliance forms (updated 12/2016)

Application to Serve as an Impartial Physician (updated 11/2014)

Average Weekly Wage Computation Schedule (Form 127)

Conference Memorandum (Form 140) (updated 7/2015)

Complaint of Improper Claims Handling Against an Insurer (Form 130)

CR-28 Massachusetts Workers' Compensation COLA Data Form

DOR Lien Release Request Guidance

Employee Biographical Data Form (Form 160)

Employee Claim (Form 110) (updated 7/2013)

Employee Earning Report (Form 126) (Updated 7/2013)

Employee's Hearing Memorandum (Form 161) (updated 7/2013)

Employee's Claim for Post-Lump Sum Medical Mediation (Form 110A)

Employer Consent to Lump Sum Agreement (Form 116A) (updated 7/13)

Employer First Report of Injury (Form 101) Can only be filed electronically

Health Care Provider Complaint Form (Form134)

Individual Written Rehabilitation Program (Form 151)

Insurance Certification Request Form

Insurer's Complaint for Modification, Discontinuance or Recoupment of Compensation (Form 108) (updated 7/2013)

Insurer's Hearing Memorandum (Form 162) (updated 7/2013)

Insurer's Notification of Acceptance, Resumption, Termination or Modification of Weekly Compensation (Form 107) (updated 7/2013)

Insurance Inquiry Form (updated 4/2014)

Insurer's Notification of Denial (Form 104) (updated 7/2013)

Insurer's Notification of Payment (Form 103)

Insurer's Notification of Termination or Modification of Weekly Compensation During Payment-Without-Prejudice Period (Form 106)

Insurer's Request for Post-Lump Sum Medical Mediation (Form 108-A)

Last Best Offer at Conference (Form 141)

Lien Disclosure (Form 116C)

Lump Sum Agreement for Injuries On or After 11/1/1986 (Form 117) (updated 7/2017)

Lump Sum Agreement for Injuries Before 11/1/1986 (Form 117A)

MGL c. 152, §65B Appeal of Cancellation or Termination of Policy

Mileage Reimbursement Form for VR Providers

Motion for Expedited Conference (Form 125)

(updated 7/2013)

Notification of Arbitration Award (Form 124A)

Notice of Change/Appearance of Counsel (Form 114)

Notification of Withdrawal of Claim or Complaint (Form 109)

OEVR Provider Quarterly Report for Closed Cases - No RTW

OEVR Provider Quarterly Report for Closed Cases - RTW

OEVR Provider Quarterly Report for Open Cases

Poster - Notice to Employees

Referral for Mandatory Meeting

Request for Lump Sum Conference (Form 116)

Request to Records Access Office for File Information

Request for §§ 37/37A Proceedings/Agreement Forms (Form 122 and 123)

Request for § 46A Conference in Conjunction with Lump Sum Under § 48 (Form 46A) (updated 3/2011)

Request for Speedy Conference Because of Hardship (Form 131) (updated 7/2013)

Section 15 Calculator Version 8.5 (updated 4/2012)

Section 15 Interactive Petition v.2.62 (updated 5/2012)

Section 19 Agreement (Form 19)

Section 19A Medical Mediation Agreement (Form 19A)

Section 50 Interest Calculator - 3/09

Third Party Claim/Notice of Lien (Form 115)

Utilization Review (UR) Agent Complaint Form (Form 133A) (updated 3/2015)

Verification of Massachusetts Workers' Compensation Coverage for Out-of-State employers operating in Massachusetts (Form 154)

W-9 -  Request for Taxpayer Identification Number and Certification

Feedback

Tell us what you think