Affidavit Of Employee In Application For Trust Fund Benefits {170}

FORM 170 - AFFIDAVIT OF EMPLOYEE IN APPLICATION FOR TRUST FUND BENEFITS. This form is used by injured workers in Massachusetts to apply for workers' compensation benefits through the Workers' Compensation Trust Fund (WCTF) when their employer did not carry the legally required workers' compensation insurance at the time of the injury. This form is a sworn affidavit in which the employee provides key personal details, such as their name, address, and contact information, as well as information about the employer, the date and location of the injury, names of any witnesses, and wage details. The claimant affirms under penalty of perjury that they were injured while working, that their employer was uninsured, and that they are seeking benefits from the WCTF as a result. www.FormsWorkflow.com