Commonwealth of Massachusetts Department of Industrial Accidents (DIA) Form 110, Employee’s Claim Instructions
This form contains 62 fields organized into 20 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Attorney Signature and Date | ||
| Attorney Signature | Text |
Enter the attorney's signature.
|
| Signature Date | Date |
Enter the date the attorney signed the form.
|
| DIA Board Number | ||
| DIA Board Number | Text |
Enter the DIA Board number, if known.
|
| Employee Attorney Information | ||
| Employee Attorney Name, Address, and BBO# | Text |
Provide the full name, mailing address, and BBO# of the employee's attorney.
|
| Attorney's Email Address | Text |
Enter the required email address of the employee's attorney.
|
| Attorney's Telephone Number | Text |
Provide the telephone number of the employee's attorney.
|
| Employee Information | ||
| Employee's Name | Text |
Enter the employee's full name, including last name, first name, and middle initial.
|
| Social Security Number | Text |
Enter the employee's Social Security Number.
|
| Home Telephone Number | Text |
Enter the employee's home telephone number.
|
| Date of Birth | Date |
Enter the employee's date of birth.
|
| Number of Dependents | Text |
Enter the total number of dependents the employee has.
|
| Home Address | Text |
Enter the employee's full home address, including street number, street name, city, state, and zip code.
|
| Employee's Email Address | Text |
Enter the employee's email address if available.
|
| Employee's Native Language Code | Text |
Enter the code for the employee's native language.
|
| Employee Occupation and Wage | ||
| Employee Regular Occupation | Text |
Enter the employee's regular occupation or job title.
|
| Average Weekly Wage | Number |
Enter the employee's average weekly wage.
|
| Actual Wage | Checkbox |
Check this box if the average weekly wage entered is an actual amount.
|
| Estimated Wage | Checkbox |
Check this box if the average weekly wage entered is an estimated amount.
|
| Employee Signature and Date | ||
| Employee Signature | Text |
Enter the employee's or claimant's signature.
|
| Signature Date | Date |
Enter the date the form was signed.
|
| Employer and Carrier Information | ||
| Employer's Name and Address | Text |
Provide the full name and address of the employer, including number, street, city, state, and zip code.
|
| Employer Industry Code | Text |
Enter the industry code for the employer as specified on the reverse side of the form.
|
| Workers' Compensation Insurance Carrier's Address and Telephone Number | Text |
Provide the address and telephone number of the workers' compensation insurance carrier, referring to instructions on the reverse side for details.
|
| First Injury and Body Part Codes | ||
| First Injury Code | Text |
Enter the code corresponding to the first injury.
|
| First Body Part Code | Text |
Enter the code corresponding to the body part affected by the first injury.
|
| Injury and Claim Details | ||
| Date of Injury | Date |
Enter the date when the injury occurred.
|
| Insurer's Case Claim Number | Text |
Provide the case or claim number assigned by the insurer.
|
| First Day of Incapacity | Date |
Enter the first day the employee was totally or partially incapacitated from earning wages.
|
| Fifth Day of Incapacity | Date |
Enter the fifth day the employee was totally or partially incapacitated from earning wages.
|
| Date of Death | Date |
If the employee has died, enter the date of death.
|
| Injury and Occurrence Description | ||
| Injury Description | Text |
Provide a detailed description of the injury, including the body parts affected.
|
| How Injury/Exposure Occurred | Text |
Briefly describe how the injury or exposure occurred and which body parts were involved.
|
| Insurer Payment Information | ||
| Insurer Payments - Yes | Checkbox |
Check this box if the insurer has made any payments on your claim.
|
| Insurer Payments - No | Checkbox |
Check this box if the insurer has not made any payments on your claim.
|
| Type of Benefits and Amounts | Text |
Specify the type of benefits and amounts that the insurer has paid on the claim.
|
| Amount of Payments | Number |
Enter the total monetary amount the insurer has paid on the claim.
|
| Medical Treatment Information | ||
| Medical Treatment Facility Name and Address | Text |
Enter the name and address of the facility where the employee was first treated.
|
| Treating Physician Name | Text |
Enter the full name of the treating physician.
|
| Other Benefits Claimed | ||
| Survivor's Benefits | Checkbox |
Check this box if claiming survivor's benefits under Section 31.
|
| Burial Expenses | Checkbox |
Check this box if claiming burial expenses under Section 33.
|
| Medical Expenses | Checkbox |
Check this box if claiming medical expenses under Sections 13 and 30.
|
| Other Benefits | Checkbox |
Check this box if claiming other benefits not listed, and specify the relevant section in the provided field.
|
| Other Benefits Claimed Specification | Text |
Please specify the other benefits claimed.
|
| Partial Incapacity Claim | ||
| Sec. 35 Partial Incapacity Comp. | Checkbox |
Check this box if you are claiming benefits for partial incapacity compensation under Section 35 of the law.
|
| First Partial Incapacity Compensation Start Date | Date |
Enter the start date of the first period for which partial incapacity compensation is claimed.
|
| First Partial Incapacity Compensation End Date | Date |
Enter the end date of the first period for which partial incapacity compensation is claimed.
|
| Second Partial Incapacity Compensation Start Date | Date |
Enter the start date of the second period for which partial incapacity compensation is claimed.
|
| Second Partial Incapacity Compensation End Date | Date |
Enter the end date of the second period for which partial incapacity compensation is claimed.
|
| Return to Work Status | ||
| Returned to Work: Yes | Radiobutton |
Check this box if the employee has returned to work.
|
| Returned to Work: No | Radiobutton |
Check this box if the employee has not returned to work.
|
| Second Injury and Body Part Codes | ||
| Second Injury Code | Text |
Enter the code for the second injury as described in section 17a.
|
| Second Body Part Code | Text |
Enter the code for the second body part involved in the injury as described in section 17a.
|
| Specific Compensation Claim | ||
| Specific Compensation Claim, Sec. 36 | Checkbox |
Check this box if you are claiming specific compensation under Section 36.
|
| Specific Compensation Amount | Number |
Enter the specific compensation amount being claimed.
|
| Third Injury and Body Part Codes | ||
| Third Injury Code | Text |
Provide the third injury code related to how the injury or exposure occurred.
|
| Third Body Part Code | Text |
Provide the third body part code related to the body part(s) involved in the injury or exposure.
|
| Total Temporary Incapacity Claim | ||
| Section 34 Total Temporary Incapacity Claim | Checkbox |
Check this box if you are claiming total temporary incapacity compensation as described in Section 34 of the law.
|
| First Total Temporary Incapacity From Date | Date |
Enter the start date of the first period of total temporary incapacity for which compensation is claimed.
|
| First Total Temporary Incapacity To Date | Date |
Enter the end date of the first period of total temporary incapacity for which compensation is claimed.
|
| Second Total Temporary Incapacity From Date | Date |
Enter the start date of the second period of total temporary incapacity for which compensation is claimed.
|
| Second Total Temporary Incapacity To Date | Date |
Enter the end date of the second period of total temporary incapacity for which compensation is claimed.
|
| Witness Names | ||
| Witness Name | Text |
Enter the name of a witness to the incident.
|