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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

Form 19 - Section 19 Agreement

Form 19A - Section 19A Medical Mediation Agreement - Updated 2/1/2022

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 - can only be filed via our online CMS system

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

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

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

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

Form 109 - Notification of Withdrawal of Claim or Complaint 

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

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

Form 112 - Appeal to Reviewing Board

Form 112A - Affidavit in Support of Request for Waiver of Filing Fee Under § 11C

Form 113: Agreement to Pay Compensation - Effective 7/1/2020, Forms 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. Please be advised you do not need to include a coversheet

Form 114 - Notice of Change/Appearance of Counsel - can only be filed via our online CMS system

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

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

Form 116A - Employer Consent to Lump Sum Agreement 

Form 116B - Addendum to Lump Sum Agreement: Vocational Rehabilitation Status 

Form 116C - Lien Disclosure Form 

Form 117 - Lump Sum Settlement Agreement for Injuries On or After 11/1/1986 

Form 117A - Lump Sum Settlement Agreement for Injuries Before 11/1/1986

Uniform Lump Sum Settlement Employee Affidavit Updated 1/31/2022

Form 121 - Appeal of Conference Order 

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 

Form 125 - Motion for Expedited Conference

Form 126 - Employee Earning Report 

Form 127 - Average Weekly Wage Computation Schedule

Form 130 - Complaint of Improper Claims Handling Against an Insurer 

Form 131 - Request for Speedy Conference Because of Hardship 

Form 132 - Affidavit in Support of Employee's Request for Speedy Conference Because of Hardship

Form 133A - Utilization Review (UR) Agent Complaint

Form 134 - Health Care Provider Complaint

Form 136 - Affidavit of Indigence and Request for Waiver of § 11A(2) Fees

Form 140 - Conference Memorandum 

Form 141 - Last Best Offer at Conference

Form 151 - Individual Written Rehabilitation Program 

Form 152 - Amendment, Suspension or Closure of Vocational Rehabilitation Plan 

Form 153 - Affidavit of Exemption for Certain Corporate Officers or Directors  (Updated 2/2/2022)

Form 154 - Verification of Massachusetts Workers' Compensation Coverage for Out-of-State Employers Operating in Massachusetts

Form 160 - Employee's Biographical Data Sheet 

Form 161 - Employee's Hearing Memorandum 

Form 162: Insurer's Hearing Memorandum

Form 170 - Affidavit of Employee in Application for Trust Fund Benefits

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