DIA numerical form list

See all the numerical forms used by the Department of Industrial Accidents (DIA). We also have forms that don't have numbers. Please refer to our alphabetical form list for all forms.

Forms by Number

CR-28 Massachusetts Workers' Compensation COLA Data Form

Massachusetts Workers' Compensation COLA Offset Worksheet 

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

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

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

Form 101 - Employer's First Report of Injury/Illness can only be filed via a DIA online account. - This form is filed when there are 5 or more full or partial calendar days of disability, and they do not need to be consecutive.

Form 103 - Insurer's Notification of Payment - can only be filed via our online CMS system with your online account.

Form 104 - Insurer's Notification of Denial - can only be filed via our online CMS system with your online account.

Form 105 - Agreement to Extend 180 Day Payment-Without-Prejudice - Effective 7/1/2020, Forms 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. Please be advised you do not need to include a coversheet

Form 106 - Insurer's Notification of Termination or Modification of Weekly Compensation During Payment-Without-Prejudice Period - can only be filed via our online CMS system with your online account.

Form 107 - Insurer's Notification of Acceptance, Resumption, Termination or Modification of Weekly Compensation -  can only be filed via our online CMS system with your online account.

Form 108 - Insurer's Complaint for Modification, Discontinuance or Recoupment of Compensation - can only be filed via our online CMS system See Administrative Bulletin # 4 on how to file Attachments

Form 108-A - Insurer's Request for Post-Lump Sum Medical Mediation - can only be filed via our online CMS system with your online account.

Form 109 - Notification of Withdrawal of Claim or Complaint - If the case is before a judge, email it to the judge and their assistant. If it is scheduled for a Conciliation, email to the conciliator.

Form 110 - Employee Claim - Effective May 23, 2020 this form can only be filed via our online CMS system  See Administrative Bulletin # 4 on how to file Attachments. However, an injured worker representing themselves may still fill out the form and mail it in, complete with attachments, to our Boston address located at the top of the form.

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 - can only be filed via our online CMS system with your online account.

Form 112 - Appeal to Reviewing Board 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. The appeal fee must be mailed in.

Form 112A - Affidavit in Support of Request for Waiver of Filing Fee Under § 11C Can be mailed to the 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

Form 113: Agreement to Pay Compensation - This completed form must be emailed  DIA-Form113conciliation@mass.gov. 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. You don't need a coversheet

Form 114 - Notice of Change/Appearance of Counsel can only be filed via our online CMS system with your online account. If you are filing a withdrawal of appearance, you need to fill out the form and mail it to the Boston DIA, the address of which is at the top of the form.

Form 115 - Third Party Claim/Notice of Lien - can only be filed via our online CMS system with your online account.

Form 116 - Request for Lump Sum Conference -  can only be filed via our online CMS system with your online account.

Form 116A - Employer Consent to Lump Sum Agreement - This must be emailed or mailed to the Conciliator or the Judge and their assistant hearing the lump sum. 

Form 116B - Addendum to Lump Sum Agreement: Vocational Rehabilitation Status - This must be emailed or mailed to the Conciliator or the Judge and their assistant hearing the lump sum.

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

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

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

Uniform Lump Sum Settlement Employee Affidavit - This must be emailed or mailed to the Conciliator or the Judge and their assistant hearing the lump sum. Updated 1/31/2022

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

Form 121A - Agreement That No Impartial Physician Report Is Required - Submitted via email to the administrative judge and their assistant hearing the case.

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

Form 122: Request for Sections 37/37A Proceedings  - Fill out the form, print and mail or deliver two copies of the entire package. One gets delivered to the 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: Request for Sections 37/37A Agreements  - Fill out the form, print and mail or deliver it to our Boston address at the top of the form, attention to the Trust Fund for their approval. 

Form 124A - Notification of Arbitration Award 

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

Form 126 - Employee Earning Report This is sent to the insurance company located in Box 14. 

Form 127 - Average Weekly Wage Computation Schedule - This is filled out by the employer and is usually submitted before a scheduled Conciliation. It can be emailed to the Conciliator.

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

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

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

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

Form 134 - Health Care Provider Complaint (Update 8/2022) - Email to Diane.Neelon@mass.gov AND Jane.Bennett@mass.gov

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

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

Form 141 - Last Best Offer at Conference -  Email to the Administrative Judge and their assistant assigned to the case and their assistant.

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

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

Form 153 - Affidavit of Exemption for Certain Corporate Officers or Directors  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)

Form 154 - Verification of Massachusetts Workers' Compensation Coverage for Out-of-State Employers Operating in Massachusetts - Email to Patrick.Allosso@mass.gov.

Form 160 - Employee's Biographical Data Sheet - Email by the employee's attorney (or the employee if they are pro se) to the administrative judge hearing the case, their assistant and opposing counsel.

Form 161 - Employee's Hearing Memorandum - Email by the employee's attorney (or the employee if they are pro se) to the administrative judge hearing the case, their assistant and opposing counsel.

Form 162: Insurer's Hearing Memorandum - email by the Insurers Attorney to the administrative judge hearing the case, their assistant and opposing counsel.

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

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