Forms by Number
CR-28 Massachusetts Workers' Compensation COLA Data Form
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 - 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
- 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
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
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
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