Forms by Number
Form 19 - Section 19 Agreement
Form 19A - Section 19A Medical Mediation Agreement
Form 46A - Request for § 46A Conference in Conjunction with Lump Sum Under § 48
Form 101 - Employer's First Report of Injury/Illness can only be filed via a DIA online account.
Form 103 - Insurer's Notification of Payment (updated 7/2013)
Form 104 - Insurer's Notification of Denial (updated 7/2013)
Form 105 - Agreement to Extend 180 Day Payment-Without-Prejudice (updated 2/2017)
Form 106 - Insurer's Notification of Termination or Modification of Weekly Compensation During Payment-Without-Prejudice Period (updated 7/2013)
Form 107 - Insurer's Notification of Acceptance, Resumption, Termination or Modification of Weekly Compensation (updated 7/2013)
Form 108 - Insurer's Complaint for Modification, Discontinuance or Recoupment of Compensation (updated 7/2013)
Form 108-A - Insurer's Request for Post-lump Sum Medical Mediation
Form 109 - Notification of Withdrawal of Claim or Complaint (updated 7/2013)
Form 110 - Employee Claim (updated 7/2013)
- Directions on how to fill out the Form 110 - English
- Directions on how to fill out the Form 110 - Arabic
- Directions on how to fill out the Form 110 - Cape Verdean
- Directions on how to fill out the Form 110 - Chinese
- Directions on how to fill out the Form 110 - Haitian Creole
- Directions on how to fill out the Form 110 - Khmer
- Directions on how to fill out the Form 110 - Portuguese
- Directions on how to fill out the Form 110 - Spanish
- Directions on how to fill out the Form 110 - Vietnamese
Form 110-A - Employee's Claim for Post-Lump Sum Medical Mediation
Form 112 - Appeal to Reviewing Board (updated 7/2013)
Form 112A - Affidavit in Support of Request for Waiver of Filing Fee Under § 11C (updated 7/2013)
Form 113 - Agreement to Pay Compensation (updated 5/2018)
Form 114 - Notice of Change/Appearance of Counsel (updated 7/2013)
Form 115 - Third Party Claim/Notice of Lien (updated 7/2013)
Form 116 - Request for Lump Sum Conference (updated 7/2013)
Form 116A - Employer Consent to Lump Sum Agreement (updated 7/2013)
Form 116B - Addendum to Lump Sum Agreement: Vocational Rehabilitation Status (updated 1/2015)
Form 116C - Lien Disclosure Form (updated 7/2013)
Form 117 - Lump Sum Settlement Agreement for Injuries On or After 11/1/1986 (Updated 1/2018)
Form 117A - Lump Sum Settlement Agreement for Injuries Before 11/1/1986
Form 121 - Appeal of Conference Order (updated 8/2015)
Form 121A - Agreement That No Impartial Physician Report Is Required
Form 122 and Form 123 - Request for §§ 37/37A Proceedings/Agreement Forms
Form 124A - Notification of Arbitration Award (updated 7/2013)
Form 125 - Motion for Expedited Conference (updated 7/2013)
Form 126 - Employee Earning Report (updated 7/2013)
Form 127 - Average Weekly Wage Computation Schedule
Form 130 - Complaint of Improper Claims Handling Against an Insurer (updated 7/2013)
Form 131 - Request for Speedy Conference Because of Hardship (updated 7/2013)
Form 132 - Affidavit in Support of Employee's Request for Speedy Conference Because of Hardship (updated 7/2013)
Form 133A - Utilization Review (UR) Agent Complaint (updated 3/2015)
Form 134 - Health Care Provider Complaint
Form 136 - Affidavit of Indigence and request for Waive of § 11A(2) Fees (updated 7/2013)
Form 140 - Conference Memorandum (updated 11/2017)
Form 141 - Last Best Offer at Conference (updated 7/2013)
Form 151 - Individual Written Rehabilitation Program (updated 2/2014)
Form 152 - Amendment, Suspension or Closure of Vocational Rehabilitation Plan (updated 7/2013)
Form 153 - Affidavit of exemption for Certain Corporate Officers or Directors
Form 160 - Employee's Biographical Data Sheet (updated 7/2013)
Form 161 - Employee's Hearing Memorandum (updated 8/2013)
Form 162 - Insurer's Hearing Memorandum (updated 7/2013)
Form 170 - Affidavit of Employee in Application for Trust Fund Benefits (updated 7/2013)