Massachusetts > Workers Comp
Employees Claim With Filing Instructions 110 - Massachusetts
| Employees Claim With Filing Instructions Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 110 The Commonwealth of Massachusetts Department of Industrial Accidents Department 110 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 http://www.mass.gov/dia DIA Board # (If Known): EMPLOYEE'S CLAIM FOR USE BY EMPLOYEES OR DEPENDENTS CLAIMING BENEFITS AS A RESULT OF INJURY OR DEATH. ALL OTHER CLAIMANTS SHOULD USE FORM 115 IMPORTANT - INSTRUCTIONS AND CODES ON THE REVERSE SIDE - Please Print Legibly or Type - Unreadable forms will be returned. 1. Employee's Name (Last, First, MI): E M P L O Y E E 6. Home Address (No., Street, City, State & Zip Code): 2. Social Security Number*: 3. Home Telephone No.: 4. Date of Birth: 5. # of Dependents: 7. Employee's E-mail address (if available): 7a . Employee's Native Language Code: ________ 8. Name, Address and BBO# of Employee's Attorney (if no attorney leave blank)**: 9. Attorney's E-mail address (Required): 9a. Attorney's Telephone No.: E M P L O Y E R 10. Employer's Name & Address (No., Street, City, State & Zip Code): 10a. Industry Code (See Reverse Side): 11. Workers' Compensation Insurance Carrier's Address and Tel. No. (NOT LOCAL AGENT/ADMINISTRATOR - See Instructions on reverse side): I N J U R Y I N F O R M A T I O N 12. DATE OF INJURY (mm/dd/yyyy): 13. FIRST day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy): 15. If Employee has Died, Date of Death (mm/dd/yyyy): 12a. Insurer's Case/Claim #: 14. FIFTH day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy): 16. Describe Injury (Lower Back..., leg..., arm... etc.): 17a. Injury Code(s) a. b. Body Part Code(s) to body part a. to body part b. to body part c. 17. Briefly Describe How Injury/Exposure Occurred and Body Part(s) involved: 18. Name(s) of Witness(es): 19. Employee's Regular Occupation: 20. Average Weekly Wage: Actual c. 21. Has Employee Returned to Work?: $_____________________ 22. Has the Insurer Made Any Payments On Your Claim? Yes Yes No Estimated No If Yes - Indicate Type of Benefits and Amounts (Medical Bills, Wages, etc.): in the amount of $ 23. Section(s) of Law Claimed. Check all appropriate boxes below and attach documentation as required by M.G.L. c 152, § 7G, §10(1) and 452 CMR 1.07. B E N E F I T S C L A I M E D a. Sec. 34 Total, Temporary Incapacity Comp. from (date): from from b. Sec. 35 Partial Incapacity Comp. from (date): from from c. Sec. 36 d. Sec. 31 Specific Comp. in the Amount of $ Survivor's Benefits e. Sec. 33 Burial Expenses f. Secs. 13 & 30 Medical Expenses g. Other (Specify Sec): 25. Name of Treating Physician: 27. Date (mm/dd/yyyy): 29. Date (mm/dd/yyyy): Form 110 to to to to and and 24. Name and Address of Facility Where Employee was First Treated: 26. Employee's/Claimant's Signature: 28. Attorney's Signature (if applicable): *Disclosure of Social Security Number is Voluntary. It will aid in the processing of your claim. **Representation by an attorney is not required (see instructions on reverse side). - Revised 7/2010 - Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com EMPLOYEE'S CLAIM FILING INSTRUCTIONS 1. WHEN TO FILE: File this form if you have been injured on the job and your employer's workers' compensation insurer (the insurer) has denied your initial claim and/or is disputing any part of your claim and refuses to pay the compensation that you believe you are entitled. Please fill out the form completely and accurately. The Department of Industrial Accidents (DIA) is the agency that handles all disputed workers' compensation claims. You do not need to be represented by an attorney in order to file a Form 110. You may represent yourself in your claim. The term that applies to self representation is PRO SE. Initiating a claim PRO SE does not prevent you from getting an attorney later. If you need assistance, please call 1-800-323-3249 ext. 470. 2. WHERE TO FILE: The original form must be mailed to the DIA at the address shown on the front of the form. A copy must also be provided to the employer as well as the insurer. We recommend that the employee keep a third copy for their own records. When an employee is represented by counsel, this form must be sent via certified mail to the insurer. Please be advised - claims for compensation must be accompanied by proper documentation in accordance with M.G.L. c. 152, §7G & 452 CMR 1.07. 3. EMPLOYER'S REQUIREMENTS: The law requires that all employers in Massachusetts carry a valid workers' compensation insurance policy at all times for all of their employees in the event of an industrial injury. Also, the employer must provide the name and address of the workers' compensation insurer upon request of an employee. If the employer refuses to provide this information or does not carry workers' compensation insurance, notify the DIA immediately. 4. EMPLOYEE'S SIGNATURE & DATE IN BOXES 26 & 27: This form may be filed by the Employee or the Employee's Attorney (if applicable). However, in all cases the Employee must sign and date this form. NATIVE LANGUAGE CODES 1 English / 2 Portuguese / 3 Haitian Creole / 04 Spanish / 5 Chinese / 6 Vietnamese / 7 Cape Verdean / 9 Other INDUSTRY CODES Agriculture, Forestry and Fishing 01 Agriculture Production - Crops 02 Agriculture Production - Livestock 07 Agricultural Services 08 Forestry 09 Fishing, Hunting and Trapping Mining 10 Metal Mining 12 Coal Mining 13 Oil and Natural Gas 14 Nonmetallic Minerals, Except Fuels Construction 15 General Building Contractors 16 Heavy Construction, Ex. Building 17 Special Trade Contractors Manufacturing 20 Food and Kindred Products 21 Tobacco Products 22 Textile Mill Products 23 Apparel and Other Textile Products 24 Lumber and Wood Products 25 Furniture and Fixtures 26 Paper and Allied Products 27 Printing and Publishing 28 29 30 31 32 33 34 35 36 37 38 39 Chemicals and Allied Products Petroleum and Coal Products Rubber and Misc. Plastic Products Leather and Leather Products Stone, Clay and Glass Products Primary Metal Industries Fabricated Metal Products Industrial Machinery and Equipment Electronic and Other Electrical Equipment Transportation Equipment Instruments and Related Products Miscellaneous Manufacturing Industries 51 Wholesale Trade - Non-durable Goods Retail Trade 52 Building Materials and Garden Supplies 53 General Merchandizing 54 Food Stores 55 Automotive Dealers and Service Stations 56 Apparel and Accessory Stores 57 Furniture and Home Furnishing Stores 58 Eating an
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