Commonwealth of Massachusetts Department of Industrial Accidents Form 110, Employee’s Claim Completed Form Examples and Samples
Find clear, filled-out examples of the Commonwealth of Massachusetts Department of Industrial Accidents Form 110, Employee’s Claim. Our detailed samples guide you through correctly completing the MA DIA Form 110 for your workers' compensation case.
Massachusetts DIA Form 110 Example – Employee’s Claim for Workplace Injury
How this form was filled:
This is an example of a completed Commonwealth of Massachusetts Department of Industrial Accidents (DIA) Form 110. It illustrates a claim filed by an employee who suffered a lower back injury while lifting heavy materials at a construction site. The form includes all necessary employee, employer, and injury details.
Information used to fill out the document:
- Employee Name: Alex Williams
- Employee Address: 456 Oak Avenue, Worcester, MA 01608
- Social Security Number: XXX-XX-6789
- Date of Birth: 05/20/1990
- Number of Dependents: 2
- Employer Name: Boston Construction Corp.
- Employer Address: 789 Granite St, Boston, MA 02101
- Employer's Insurance Carrier: Liberty Mutual Insurance
- Date of Injury: 10/15/2025
- Time of Injury: 10:30 AM
- Place of Injury: Construction site at 100 Beacon St, Boston, MA
- Description of Injury: Employee was lifting a heavy box of tiles and felt a sharp pain in the lower back.
- Body Part(s) Injured: Lower back
- Last Day Worked: 10/15/2025
- Return to Work Date: Not yet returned
- First Medical Treatment: UMass Memorial Medical Center - Emergency Department
- Treating Physician: Dr. Emily Carter
- Form Signature: Alex Williams
- Date Signed: 11/05/2025
What this filled form sample shows:
- Clearly states employee, employer, and insurance information in the designated sections.
- Provides a specific and detailed description of the injury incident, as required by the form.
- Accurately records the date of injury and last day of work, which are critical for claim processing.
- Includes information on medical treatment received, linking the injury to a medical provider.
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 a workers' compensation claim for a back injury sustained at a construction site. |
| Filing Purpose: | To formally notify the Department of Industrial Accidents and the employer's insurer of a workplace injury and to claim benefits. |
| Categories: | industrial accident forms, VA claim forms, SSA forms, employee forms, ACH forms |
| Created: | February 12, 2026 04:38 AM |