Complaint Of Improper Claims Handling Against Insurer {130}

The Commonwealth of Massachusetts Department of Industrial Accidents Department 130 Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111 - 1750 Info. Line (800) 323 - 3249 Inside Mass. / (857) 321 - 7470 Outside Mass. www.mass.gov/dia COMPLAINT OF IMPROPER CLAIMS HANDLING AGAINST AN INSURER DIA Board # (If Known): FORM 130 Form 130 - Revised 7/2019 - Reproduce as needed. *Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents. Please Print Clearly or Type. Unreadable forms will be returned. ) : 19. Date Prepared (mm/dd/yyyy): The purpose of this form is to request the Department of Industrial Accidents (DIA), Office of Claims Administration to condu ct a preliminary investigation into the claims handling practices of an Insurer. Upon completion of our investigation you will be no tified of our findings. Please note - The DIA can only determine if the matter should be further investigated by the Division of Insuranc e. The DIA can NOT award damages or any type of award or compensation to a complainant. 4. DIA Board Number (if known): 5. Date of Injury (mm/dd/yyyy): NATURE OF COMPLAINT (attach additional sheets if necessary) Specify dates of complaint, date claim has been paid through, any weeks not paid, etc. American LegalNet, Inc. www.FormsWorkFlow.com