Commonwealth of Massachusetts Department of Industrial Accidents (DIA) Form 110, Employee’s Claim Completed Form Examples and Samples
Explore detailed examples and samples of the Commonwealth of Massachusetts DIA Form 110, Employee’s Claim. See how to properly fill out this crucial workers' compensation form with our clear, completed samples to ensure your claim is filed correctly.
Massachusetts DIA Form 110 Example – Employee’s Claim for a Work Injury
How this form was filled:
This example shows a completed DIA Form 110 for a construction worker who sustained a back injury while lifting heavy materials. It details the employee and employer information, the specific circumstances of the injury, the nature of the medical condition, and the period of disability for which compensation is being claimed.
Information used to fill out the document:
- Employee Name: Maria Garcia
- Employee Address: 123 Maple St, Worcester, MA 01608
- Date of Birth: 06/15/1988
- Employer Name: Boston Construction Co.
- Employer Address: 456 Commercial St, Boston, MA 02109
- Insurance Carrier: Liberty Mutual Insurance
- Date of Injury: 12/05/2025
- Time of Injury: 10:30 AM
- Place of Injury: Construction site at 789 Atlantic Ave, Boston, MA
- Description of Injury: While lifting a heavy box of construction materials, I felt a sharp, sudden pain in my lower back.
- Nature of Injury: Herniated Disc
- Part of Body Affected: Lower Back
- First Day Unable to Work: 12/06/2025
- Returned to Work Date: Still out of work
- Average Weekly Wage: $1,200.00
- Medical Treatment Received From: UMass Memorial Medical Center
- Date Form Signed: 01/10/2026
What this filled form sample shows:
- Complete and accurate information for the Employee, Employer, and Insurance Carrier sections.
- A detailed and specific description of the accident and how the injury occurred.
- Clear identification of the body part injured and the medical nature of the injury.
- Correctly stated first day of disability and calculation of average weekly wage, which are crucial for benefit calculation.
Form specifications and details:
| Form Name: | Form 110 - Employee’s Claim |
| Issuing Authority: | Commonwealth of Massachusetts, Department of Industrial Accidents (DIA) |
| Use Case: | Employee filing an initial claim for workers' compensation benefits (e.g., medical costs, lost wages) after a work-related injury that resulted in more than five days of lost work time. |
Created: February 12, 2026 05:04 AM
