DIA 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) This must be emailed to the Conciliator or the Judge and their assistant hearing the lump sum.

Affidavit for Builders, Contractors, Plumbers, and Electricians - Gets filed with the city or town the work is being done in.

Affidavit of Employee in Application for Trust Fund Benefits (Form 170) Gets sent as part of the supporting documentation for claim against the Trust Fund.

Affidavit of Exemption for Certain Corporate Officers (Form 153) can be filed several different ways: Email to DIAForm153@mass.gov, FAX (617) 727-7749, in person or via regular mail to the address at the top of the form.(Updated 2/2/2022)

Affidavits for General Businesses - Gets filed with the city or town where the business is located.

Affidavit of Indigence and Request for Waiver of §11A(2) Fees (Form 136) - Email to Deborah.Keefe@mass.gov AND Maryanne.Fitzpatrick@mass.gov.

Affidavit in Support of Employee's Request for a Speedy Conference Because of Hardship (Form 132) - Email to Deborah.Keefe@mass.gov OR Maryanne.Fitzpatrick@mass.gov

Affidavit in Support of Request for Waiver of Filing Fee Under §11C (Form 112A) - Cane be mailed to our Boston address are the top of the form or emailed. If emailing, email to either Deborah.Keefe@mass.gov OR Maryanne.Fitzpatrick@mass.gov

Agreement to Extend 180 Day Payment-Without-Prejudice Period (Form 105) - Form 105 will only be accepted via email. Please include the DIA Board Number in the upper right corner of the Form. Forms not submitted via email will not be reviewed or considered approved. Please email the completed Form 105 to DIA-Form105conciliation@mass.gov. You do not need to include a coversheet.

Agreement That No Impartial Physician Report is Required (Form 121A) - Submitted via email to the Administrative Judge hearing the case and their assistant.

Agreement to Pay Compensation (Form 113) - Form 113 will only be accepted via email. Please include the DIA Board Number in the upper right corner of the Form. Forms not submitted via email will not be reviewed or considered approved. Please email the completed Form 113 to DIA-Form113conciliation@mass.gov. You do not need to include a coversheet.

Amendment, Suspension or Closure of Vocational Rehabilitation Plan (Form 152) Emailed to the DIA Vocational Rehabilitation Review Officer by the Vocational Rehabilitation Agent. (Updated 8/3/2022)

Appeal of a Conference Order (Form 121) - Email to: Deborah.Keefe@mass.gov, Maryanne.Fitzpatrick@mass.gov AND Ingrid.Askew@mass.gov. Appeal fee must be mailed in to the Boston Address at the top of the form.

Appeal to Reviewing Board (Form 112) - Can be mailed to our Boston address at the top of the form or emailed. If emailing it can go to either Deborah.Keefe@mass.gov or Maryanne.Fitzpatrick@mass.gov.

Application to Become an Approved Utilization Review Agent and Affidavit of Compliance forms - Must be emailed to Diane.Neelon@mass.gov AND Jane.Bennett@mass.gov.

Application to Serve as an Impartial Physician - Mailed to the Boston address listed at the end of the application.

Average Weekly Wage Computation Schedule (Form 127) - This is filled out by the employer and is submitted as a supporting document at the time of the filing of a Form 108 or emailed to the assigned conciliator prior to the conciliation date.

Conference Memorandum (Form 140) - Email to the Administrative Judge assigned to the case and their assistant.

Consent of an Employer to Lump Sum Settlement (Form 116A) - This must be emailed or mailed to the Judge and their assistant or Conciliator approving the lump sum.

Complaint of Improper Claims Handling Against an Insurer (Form 130) - Mailed to the address at the top of the form.

CR-28 Massachusetts Workers' Compensation COLA Data Form 

DOR Lien Release Request Guidance - Directions on how to handle a DOR Lien Release.

Employee Biographical Data Form (Form 160) emailed by the employee's attorney (or employee if they are pro se) to the Administrative Judge hearing the case, their assistant and opposing counsel.

Employee Claim (Form 110) This form can only be filed via DIA online CMS System. See Administrative Bulletin # 4. However, an injured worker representing themselves may fill out the form and mail it, along with the required documentation, to our Boston address located at the top of the form.  

Employee Earning Report (Form 126) - This form is sent by the insurance company to the injured worker. The injured worker must fill it out and return it to the insurance company address located in Box # 14.

Employee's Hearing Memorandum (Form 161) - Emailed by the employee's attorney (or the injured worker if they represent themself) to the Administrative Judge hearing the case, their assistant and opposing counsel.

Employee's Claim for Post-Lump Sum Medical Mediation (Form 110A) - Can only be filed via your online DIA CMS/DMS account

Employer First Report of Injury (Form 101) - Can only be filed via your online DIA CMS/DMS account - This form is filed when there are 5 or more full or partial calendar days of disability, which do not need to be consecutive.

Health Care Provider Complaint Form (Form134) Email to Diane.Neelon@mass.gov AND Jane.Bennett@mass.gov (Updated 8/2022)

Individual Written Rehabilitation Program (Form 151) - Emailed to the DIA Vocational Rehabilitation Review Officer by the Vocational Rehabilitation Agent.

Insurance Certification Request Form - Use this version for a mailed in or faxed (617) 624-0985 submission. Responses to faxed requests cannot be faxed back. Use the online version if your e-mail account does not have an attachment filter. Also be advised that any returned online version in need of adjustment requires that a new online form be completely filled out and submitted with the requested adjustment incorporated into it.

Insurer's Complaint for Modification, Discontinuance or Recoupment of Compensation (Form 108) - Can only be filed via your online DIA DMS/CMS account. To find out how to file the required attachments, please read our Administrative Bulletin # 4.

Insurer's Hearing Memorandum (Form 162) - Emailed by Insurer's attorney to the Administrative Judge hearing their case, the judge's assistant and opposing counsel.

Insurer's Notification of Acceptance, Resumption, Termination or Modification of Weekly Compensation (Form 107)Can only be filed via your DIA online CMS System.

Insurance Inquiry Form

Insurer's Notification of Denial (Form 104)can only be filed via your DIA online DMS/CMS account.

Insurer's Notification of Payment (Form 103) -  can only be filed via your DIA online DMS/CMS account.

Insurer's Notification of Termination or Modification of Weekly Compensation During Payment-Without-Prejudice Period (Form 106)Can only be filed via your DIA online DMS/CMS account.

Insurer's Request for Post-Lump Sum Medical Mediation (Form 108-A) - Can only be filed via your DIA online DMS/CMS account.

Joint Pre-Hearing Memorandum - Must be filled out by both parties and emailed to the Judge hearing the case as well as the judge's assistant.

Last Best Offer at Conference (Form 141) - Emailed to the Administrative Judge and their assistant assigned to the case,

Lien Disclosure (Form 116C) - This must be emailed or mailed to the Conciliator or Administrative Judge and their assistant hearing the lump sum.

Lump Sum Settlement Agreement for Injuries On or After 11/1/1986 (Form 117) - This must be emailed or mailed to the Conciliator or Administrative Judge and their assistant hearing the lump sum.

Lump Sum Agreement for Injuries Before 11/1/1986 (Form 117A) - This must be emailed or mailed to the Conciliator or Administrative Judge and their assistant hearing the lump sum.

Uniform Lump Sum Settlement Employee Affidavit (updated 1/31/2022) - This must be emailed or mailed to the Conciliator or Administrative Judge and their assistant hearing the lump sum if the employee is not able to attend the lump sum.

MGL c. 152, §65B Appeal of Cancellation or Termination of Policy - This appeal form is filled out by employers whose workers' compensation insurance was written by the assigned risk pool and was cancelled. Send documentation supporting your objections to the address at the bottom of the form. 

Motion for Expedited Conference (Form 125) - Email to Deborah.Keefe@mass.gov AND Maryanne.Fitzpatrick@mass.gov.

Notification of Arbitration Award (Form 124A) - 

Notice of Change/Appearance of Counsel (Form 114)Can only be filed via your DIA online DMS/CMS account. However, if you are filing the form as a withdrawal of counsel, you will need to fill out the form, print it out and mail to the DIA Boston location which is listed at the to of the form.

Notification of Withdrawal of Claim or Complaint (Form 109) - If the case is before and Administrative Judge, email it to the Administrative Judge and their assistant. If it is scheduled before a Conciliator, email it to the conciliator.

OEVR Provider Quarterly Report for Closed Cases - No RTW - Emailed  to the DIA Vocational Rehabilitation Review Officer. 

OEVR Provider Quarterly Report for Closed Cases - RTW - Emailed  to the DIA Vocational Rehabilitation Review Officer.

OEVR Provider Quarterly Report for Open Cases - Emailed  to the DIA Vocational Rehabilitation Review Officer.

Posters - Notice to Employees - Needs to be placed in a common area of the workspace so employees know whom the workers' compensation insurance company is.

Poster - Notice to Employees (English)

Poster - Notice to Employees (Arabic)

Poster - Notice to Employees (Cape Verdean)

Poster - Notice to Employees (Chinese)

Poster - Notice to Employees (Haitian Creole)

Poster - Notice to Employees (Khmer)

Poster - Notice to Employees (Portuguese)

Poster - Notice to Employees (Spanish)

Poster - Notice to Employees (Vietnamese)

Referral for Mandatory Meeting - Email form and documents to Renee.Strong@mass.gov

Request for Lump Sum Conference (Form 116)Can only be filed via your DIA online CMS/DMS account

Request to Records Access Office for File Information - Can be mailed to the address on the form

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

  • Form 122 - Fill out the form, print and mail, or deliver, two copies of the entire package. One goes to he Office of Claims Administration and the other copy goes to the Trust Fund at our Boston address listed at the top of the form.
  • Form 123 - Fill out the form, print and mail, or deliver  our Boston address listed at the top of the form, attention to the Trust Fund for approval.

Request for § 46A Conference in Conjunction with Lump Sum Under § 48 (Form 46A) Email to Deborah.Keefe@mass.gov AND Maryanne.Fitzpatrick@mass.gov

Request for Speedy Conference Because of Hardship (Form 131) - Email to Deborah.Keefe@mass.gov OR Maryanne.Fitzpatrick@mass.gov

Section 15 Calculator Version 8.5 (updated 4/2012) 

Section 15 Interactive Petition v. 2.7 (updated 4/2020) Please be advised these petitions MUST be EMAILED to Edna.Smith@mass.gov

Section 19 Agreement (Form 19) - If there is a judge assigned to the case, email it to the judge and their assistant. If there is no judge assigned to the case, email it to Dele.Edebiri@mass.gov AND Michelle.Medeiros@mass.gov

Section 19A Medical Mediation Agreement (Form 19A)  - If there is a judge assigned to the case, email it to the judge and their assistant. If there is no judge assigned to the case, email it to Dele.Edebiri@mass.gov AND Michelle.Medeiros@mass.gov (Updated 2/1/2022) 

Section 50 Interest Calculator - 3/09

Third Party Claim/Notice of Lien (Form 115)can only be filed via your DIA online CMS/DMS account

Utilization Review (UR) Agent Complaint Form (Form 133A) - Email to Diane.Neelon@mass.gov AND Jane.Bennett@mass.gov

Verification of Massachusetts Workers' Compensation Coverage for Out-of-State employers operating in Massachusetts (Form 154) - Email form to Patrick.Allosso@mass.gov

W-9 -  Request for Taxpayer Identification Number and Certification - Gets filed with the Workers' Compensation Trust Fund claim.

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