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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

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 must now 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)

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 8/2014)

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 6/2017)

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 7/2015)

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

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)

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