Massachusetts > Workers Comp
Affidavit Of Employee In Application For Trust Fund Benefits 170 - Massachusetts
| Affidavit Of Employee In Application For Trust Fund Benefits Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 170 The Commonwealth of Massachusetts DIA USE ONLY Department of Industrial Accidents Department 170 Workers Compensation Trust Fund 600 Washington Street 7th Floor, Boston, Massachusetts 02111 Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 http://www.mass.gov/dia AFFIDAVIT OF EMPLOYEE IN APPLICATION FOR TRUST FUND BENEFITS I, _____________________________________, do swear and depose as follows: (Name of employee/claimant) 1. I reside at ________________________________________________________. Home telephone # _________________________________________________. 2. On the date of my injury my employer was ______________________________. The address of my employer is ________________________________________. My supervisors name is _____________________________________________. 3. While working for my employer, I was injured on _________________________. (Date of Injury) The injury occurred at _______________________________________________. (Address, city and town) Witnesses to my injury were __________________________________________ (Name and address of witness) __________________________________________ (Name and address of witness) 4. I have been informed that my employer, at the time of my injury, did not carry workers compensation insurance as required by Massachusetts law (M.G.L. c. 152, 25A). 5. I am now applying to the Workers Compensation Trust Fund (WCTF) for appropriate benefits. 6. At the time of my injury, I was earning wages of $_________ per week from my employer by CASH - CHECK. (Circle one) SIGNED UNDER THE PAINS AND PENALTIES OF PERJURY THIS ____________ DAY OF_______________ 20___ (Date) (Month) (Year) ______________________________________________ Signature of Employee/Claimant Form 170 - November 2002
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