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Commonwealth of Massachusetts Department of Industrial Accidents Form 110, Employee’s Claim, page 1

Complex · 64/100Form Complexity Index

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What this form asks for

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Massachusetts Department of Industrial Accidents (DIA) Form 110, “Employee’s Claim,” is the official form employees or eligible dependents use to initiate a disputed workers’ compensation claim for benefits related to a workplace injury or death. It captures identifying information for the employee, employer, insurer, injury details, wage information, and the specific statutory benefits being claimed (e.g., temporary total/partial incapacity, medical expenses, survivor benefits). Filing it correctly is important because it formally starts the DIA dispute process and helps ensure the claim is processed without delays or rejection for missing/illegible information. Today, this form can be filled out quickly and accurately using AI-powered services like Instafill.ai, which can also convert non-fillable PDF versions into interactive fillable forms.

Fillable fields62

Pages1

Sections16

Tables and lists1

Questions that depend on earlier answers17

Form Complexity IndexComplex, 64/100

The AI checks your answers before you download

17 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

Employee Name completeness and structure (Last, First, MI)

Validates that Employee Name is present and follows the expected order: last name, first name, and optional middle initial. The check should reject entries that are only initials, contain only a single token, or include obviously non-name placeholders (e.g., 'N/A', 'Unknown'). If validation fails, the submission should be flagged for correction because the DIA and insurer rely on the legal name to match employment and claim records.

Social Security Number (SSN) format and plausibility

Validates that the SSN, if provided (voluntary), is exactly 9 digits with optional hyphens in the standard pattern (XXX-XX-XXXX) and contains only numeric characters aside from hyphens. It should also screen for invalid values such as all zeros in any group (e.g., 000-xx-xxxx) or repeated placeholder patterns (e.g., 123-45-6789). If validation fails, the SSN should be rejected/cleared and the user prompted, since an incorrect SSN can misroute the claim or cause identity mismatches.

Phone number format validation (Employee and Attorney)

Validates that Home Telephone Number and Attorney Telephone Number (if applicable) are valid US phone numbers, including area code, and allow common punctuation and optional extensions. The system should normalize to a consistent stored format (e.g., E.164 +1XXXXXXXXXX) while preserving extension data. If validation fails, the form should be returned for correction because the DIA/insurer may need to contact the claimant or counsel promptly.

Email address format and conditional requirements (Employee and Attorney)

Validates that any provided email address matches a standard email pattern (local@domain) and does not contain spaces or invalid characters. Attorney Email is required if Attorney Name/Address/BBO# is filled, while Employee Email is optional but must be valid if present. If validation fails, the submission should be blocked or flagged because incorrect emails prevent delivery of time-sensitive claim communications.

Home address completeness and Massachusetts-style formatting

Validates that the Home Address includes street number, street name, city, 2-letter state abbreviation, and a 5-digit ZIP (optionally ZIP+4). It should also ensure the state is a valid US state code and that the ZIP is numeric and properly sized. If validation fails, the form should be rejected for correction because mailing address errors can prevent official notices and benefit checks from reaching the claimant.

Date fields format (mm/dd/yyyy) and calendar validity

Validates that all date fields (Date of Birth, Date of Injury, First Day of Incapacity, Fifth Day of Incapacity, Date of Death, signature dates, benefit period dates) are in mm/dd/yyyy format and represent real calendar dates. The check should reject impossible dates (e.g., 02/30/2025) and enforce consistent zero-padding rules if required by the system. If validation fails, the submission should be blocked because incorrect dates can change eligibility windows and benefit calculations.

And 11 more checks

Chronological consistency across injury/incapacity/death dates
Fifth day of incapacity equals first day + 4 days (rule check)
Number of dependents is a non-negative integer
Native language code is from the allowed code set
Industry code (10a) must match published industry list
Injury description and occurrence narrative minimum content
Injury codes and body part codes must be valid and paired
Average weekly wage amount format and Actual vs Estimated selection
Return-to-work and insurer payment questions are single-select and conditionally complete
Benefits claimed (Sections 34/35/36/31/33/13&30/Other) require supporting fields and valid date ranges
Signature and signature date requirements (Employee and Attorney)

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How to Fill Out MA DIA Form 110 Online for Free in 2026

What the AI walks you through.

Go to Instafill.ai and upload the Massachusetts DIA Form 110 PDF (or select it from the form library).
Enter or import the employee/claimant details (name, SSN, DOB, contact info, address, dependents, native language code, and DIA Board # if known).
Provide employer and insurer information (employer name/address, industry code, insurer carrier address/phone, and insurer case/claim number).
Complete injury and disability dates and descriptions (date of injury, first/fifth day of incapacity, date of death if applicable, injury description, how it occurred, witnesses, and injury/body-part codes).
Add work and wage details (regular occupation, average weekly wage, and whether the wage is actual or estimated; indicate whether the employee returned to work).
Select benefits claimed under M.G.L. c. 152 (e.g., Sec. 34, Sec. 35, Sec. 36, Sec. 31, Sec. 33, Secs. 13 & 30, or other) and enter any required date ranges/amounts; add treatment facility and treating physician information.
Review for completeness and legibility, then e-sign (and attorney sign if applicable), download the finalized form, and mail the original to the DIA while providing copies to the employer and insurer as instructed.

Common Mistakes in Completing MA DIA Form 110

The ones the AI is built to catch.

Using the wrong form (Form 110 vs. Form 115)

People often file Form 110 even when they are not the employee or a dependent (e.g., medical providers or other parties), because they assume “employee claim” applies to any claim. This can lead to the DIA returning the submission or delaying the case while the claimant re-files on the correct form. Confirm you are an employee or dependent claiming benefits due to injury/death; otherwise use Form 115. AI-powered tools like Instafill.ai can prompt the correct form choice based on your role and prevent mis-filing.

Illegible or incomplete identity/contact information

This form explicitly warns that unreadable forms will be returned, yet many submissions have hard-to-read names, missing middle initials, incomplete addresses, or phone numbers without area codes. The consequence is returned mail, missed notices, and processing delays. Print clearly or type, and ensure the address includes street number, city, state abbreviation, and ZIP. If the form is only available as a flat non-fillable PDF, Instafill.ai can convert it into a fillable version and validate that required contact fields are complete.

Incorrect date formats or inconsistent claim timeline

A frequent error is entering dates in the wrong format (not mm/dd/yyyy) or providing a timeline that doesn’t make sense (e.g., incapacity dates before the date of injury, or a “fifth day” that isn’t actually five days after the first day). These inconsistencies can trigger follow-up requests, disputes about eligibility periods, or delays in scheduling conferences/hearings. Use mm/dd/yyyy everywhere and double-check that the first and fifth day of incapacity align logically with the injury date. Instafill.ai can automatically format dates and flag timeline conflicts before submission.

Leaving the insurer information as the local agent/administrator

Item 11 specifically requires the workers’ compensation insurance carrier (not the local agent/administrator), but many people list the employer’s HR contact, a TPA, or an insurance broker. This can cause misdirected notices, failure to properly serve the insurer, and significant delays in dispute processing. Request the actual carrier name and its address/phone, and copy it exactly as provided on claim correspondence. Instafill.ai can help standardize insurer entries and reduce the chance of entering an agent instead of the carrier.

Missing or incorrect codes (Industry, Injury, Body Part, Native Language)

Claimants often skip code fields or enter descriptions instead of the required numeric codes (e.g., writing “construction” instead of “15–17,” or “back” instead of body part code “420”). Incorrect codes can lead to data entry errors, misclassification, and additional DIA follow-up. Use the code lists on the form and enter the numeric code(s) that best match the situation; if multiple injuries/body parts exist, use a/b/c consistently. Instafill.ai can suggest and validate codes based on your narrative and prevent mismatched injury/body-part pairings.

Vague injury description and exposure narrative

Items 16 and 17 are often filled with overly broad statements like “hurt back at work,” without describing the mechanism (lifted, slipped, repetitive motion), the specific body part(s), and what happened. Vague narratives can weaken the claim, create disputes about causation, and require supplemental statements. Provide a concise but specific account: what you were doing, what happened, and which body parts were affected (left/right if relevant). Instafill.ai can guide you with structured prompts to capture the key facts consistently.

Not completing benefit sections after checking boxes (Sec. 34/35 date ranges, Sec. 36 amount, Other section)

A common mistake is checking a benefit box (e.g., Sec. 34 or Sec. 35) but leaving the “from/to” periods blank, or claiming Sec. 36 without entering an amount. This creates an incomplete claim request and can delay adjudication or lead to partial processing. Only check benefits you are claiming and complete every associated field (date ranges and amounts) with clear periods; attach required documentation where indicated. Instafill.ai can enforce conditional logic so that selecting a benefit automatically requires the corresponding dates/amounts.

Average weekly wage entered without selecting Actual vs. Estimated (or using the wrong number)

People frequently enter a wage figure but forget to mark whether it is “Actual” or “Estimated,” or they enter an hourly rate instead of an average weekly wage. This can affect benefit calculations and may prompt the insurer/DIA to request clarification or payroll records. Enter the weekly amount (not hourly), and check the correct box to indicate whether it’s confirmed or an estimate. Instafill.ai can format currency correctly and help convert pay information into an average weekly wage when you provide pay details.

Inconsistent answers about return-to-work and insurer payments

Claimants sometimes check “Returned to Work: Yes” but also claim continuous total incapacity dates, or they check “Insurer made payments: No” while listing payment amounts (or vice versa). These contradictions can undermine credibility and slow processing while the record is reconciled. Ensure your return-to-work status matches the incapacity periods you’re claiming, and only fill the payment type/amount fields if you checked “Yes” for insurer payments. Instafill.ai can cross-check these fields and flag contradictions before you submit.

Attorney section errors (missing BBO#, missing required attorney email, or filling attorney fields when pro se)

When represented, people often omit the attorney’s BBO number or the attorney email (noted as required), or they enter the employee’s email in the attorney email field. Conversely, pro se filers sometimes partially fill attorney fields, creating confusion about representation and service requirements (e.g., certified mail to insurer when represented). If you have an attorney, complete name/address, BBO#, phone, and the attorney email; if you do not, leave attorney fields blank. Instafill.ai can apply representation logic to ensure the correct attorney fields are completed only when applicable.

Missing signatures/dates or using the wrong signer

The instructions emphasize that the employee must sign and date the form in all cases, yet submissions often arrive unsigned, undated, or signed only by the attorney. An unsigned/undated form can be rejected or treated as not properly filed, delaying the claim. Ensure the employee/claimant signs in Box 26 and dates in Box 27; if represented, the attorney signs and dates their boxes as well. Instafill.ai can add completion checks to prevent submission until all required signature/date fields are present.

Frequently Asked Questions About MA DIA Form 110

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This plan is for your MA DIA Form 110: your own AI agent fills it as often as 5 times a month. To fill other forms and upload your own, choose a Professional plan from your account.

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How does the AI fill out MA DIA Form 110?

You answer a few questions in plain words, or upload a document you already have. The AI reads what you give it and puts each answer into the right field of MA DIA Form 110, on every page, in seconds. It checks the answers against the form's own rules, and you review and change anything before you download, print or sign.

What happens to my information?

It is encrypted in transit and at rest, and it is never used to train AI.

How complex is MA DIA Form 110 to fill out?

MA DIA Form 110 has a Form Complexity Index of 64 out of 100, in the complex tier: 62 fillable fields across 1 page. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.

What is Massachusetts DIA Form 110 (Employee’s Claim) used for?

Form 110 is used by an employee (or dependents in a death claim) to file a disputed workers’ compensation claim with the Massachusetts Department of Industrial Accidents (DIA). It’s typically filed when the workers’ compensation insurer has denied the claim or is disputing benefits you believe you are owed.

Who should file Form 110, and who should use Form 115 instead?

Employees or dependents claiming benefits due to an injury or death should use Form 110. The form states that all other types of claimants should use Form 115.

Do I need an attorney to file Form 110?

No—representation by an attorney is not required, and you may file “pro se” (self-represented). You can still hire an attorney later even if you start the claim on your own.

When should I file Form 110?

You should file when you were injured on the job and the insurer has denied your initial claim and/or is disputing part of your claim and refuses to pay benefits you believe you’re entitled to. The DIA handles disputed workers’ compensation claims.

Where do I send Form 110, and who else must receive a copy?

The original must be mailed to the DIA at the address listed on the form (Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111-1750). You must also provide a copy to your employer and the insurer, and it’s recommended you keep a third copy for your records.

Do I have to send the form by certified mail?

If you are represented by an attorney, the form must be sent to the insurer via certified mail. If you are not represented, the form instructions emphasize mailing the original to DIA and providing copies to the employer and insurer.

What documentation do I need to attach to Form 110?

The instructions state that claims must be accompanied by proper documentation in accordance with M.G.L. c. 152, §7G and 452 CMR 1.07, and certain benefit sections require documentation. If you’re unsure what applies, contact the DIA information line for guidance.

Is my Social Security Number required on Form 110?

No—disclosure of your Social Security Number is voluntary. However, the form notes it will aid in processing your claim.

How do I fill out the insurer information—can I list my local agent or administrator?

No—the form specifically says to list the workers’ compensation insurance carrier (not the local agent/administrator). Use the carrier’s address and telephone number as instructed on the form.

What if my employer won’t tell me who their workers’ compensation insurer is (or has no insurance)?

Massachusetts employers are required to carry workers’ compensation insurance and must provide the insurer’s name and address upon request. If the employer refuses or does not carry insurance, the form instructs you to notify the DIA immediately.

How do I complete the injury description and the injury/body part codes (Items 16, 17, and 17a)?

In Item 16, briefly describe the injury and body part (e.g., “lower back strain” or “fractured left leg”). In Item 17, explain how it happened; then use Item 17a to enter the appropriate “Nature of Injury” code(s) and matching “Body Part Affected” code(s) from the lists provided.

What do “First day” and “Fifth day” of incapacity mean on the form?

The “First day” is the first date you were totally or partially unable to earn wages due to the injury. The “Fifth day” is the calendar date that corresponds to the fifth day of that total or partial incapacity.

How do I choose which benefits to claim in Section 23 (Sec. 34, 35, 36, 31, 33, 13 & 30)?

Check all boxes that apply to the benefits you are requesting (for example, Sec. 34 for total temporary incapacity or Sec. 35 for partial incapacity) and fill in the date ranges where required. If you claim “Other,” specify the section/type of benefit and attach any required documentation.

Can AI help me fill out Form 110 accurately?

Yes—AI tools can help you organize your information and auto-fill form fields to reduce errors and save time. Services like Instafill.ai use AI to map your details into the correct fields and help you complete the form more efficiently.

How do I fill out this Form 110 online using Instafill.ai, and what if my PDF isn’t fillable?

You can upload the Form 110 PDF to Instafill.ai, provide your claim details (injury dates, employer/insurer info, benefits claimed, etc.), and the AI will auto-fill the fields for review before you download. If the PDF is flat/non-fillable, Instafill.ai can convert it into an interactive fillable form so you can complete it electronically.

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