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

Enter the attorney's full name, complete mailing address (number, street, city, state, ZIP) and the attorney's BBO (Board of Bar Overseers) number.

Enter the attorney's e-mail address to be used for correspondence; include the full e-mail string (e.g., [email protected]). Fill only if 'Attorney - Name, Address & BBO#' is filled.

Enter the attorney's telephone number, including area code and any extension if applicable. Fill only if 'Attorney - Name, Address & BBO#' is filled.

Enter the DIA Board number associated with this claim, if known; leave blank if you do not have this number.

Enter your full home mailing address including house/building number, street, city, two‑letter state abbreviation and ZIP code (e.g., 123 Main St, Anytown, MA 02111).

Provide your primary personal or work email address where you can be contacted (leave blank only if you do not have an email).

Enter the numeric or short code that represents your native language as used by this form or agency (e.g., a two‑digit language code).

Enter the employee's full name in the order: last name, first name, and middle initial (if any).

Enter the employee's Social Security Number as issued (include hyphens if you normally use them).

Enter the employee's primary home telephone number, including area code and any necessary punctuation or extension.

Enter the employee's date of birth.

Enter the total number of dependents the employee is claiming.

Enter the employer’s full legal name followed by the street address, city, state and ZIP code.

Provide the employer’s industry classification code as shown on the form or from the NAICS/industry code list.

Enter the workers’ compensation insurance carrier’s name, street address, city, state, ZIP code and the carrier’s telephone number (not the local agent/administrator).

Enter the calendar date on which the injury occurred.

Enter the insurer's case or claim identification number exactly as provided by the insurer (include letters, numbers, or punctuation used in the official claim ID).

Enter the first calendar date the employee was totally or partially unable to work due to this injury.

Enter the calendar date corresponding to the fifth day of the employee's total or partial incapacity related to this injury.

If the employee died as a result of the injury, enter the date of death; otherwise leave this field blank.

Enter a short description of the injury (for example: lower back strain, laceration to right arm, fractured left leg) including the injured body part(s).

Provide a concise narrative of how the injury or exposure happened and list any body part(s) involved.

Enter the first injury code number or identifier that corresponds to the type of injury sustained.

Enter the code that identifies the body part affected for injury code 'a'.

Enter the second injury code number or identifier, if applicable, that corresponds to the type of injury sustained.

Enter the code that identifies the body part affected for injury code 'b'.

Enter the third injury code number or identifier, if applicable, that corresponds to the type of injury sustained.

Enter the code that identifies the body part affected for injury code 'c'.

Enter the employee's usual job title or regular occupation (e.g., Carpenter, Cashier, Office Manager).

Enter the employee's average weekly wage as reported (the typical weekly pay amount earned).

Check this box when the employee's average weekly wage amount shown is the actual (known) wage rather than an estimate.

Check this box when the employee's average weekly wage amount shown is an estimated value rather than the actual known wage.

Check this box if you are claiming survivor's benefits under Section 31 for dependents of a deceased employee.

Check this box if you are claiming burial or funeral expense reimbursement under Section 33.

Check this box if you are claiming medical expense benefits (treatment or related medical costs) under Sections 13 or 30.

Check this box if you are claiming a different type of benefit not listed above and specify the statute/section or type of benefit in the space provided.

Enter the name or statute/section and a short description of any other benefit claimed (specify the benefit or legal section for item 23.g). Fill only if 'g. Other (Specify Section)' is 'Yes'.

Check this box if the employee has returned to work.

Check this box if the employee has not returned to work.

Check this box if the insurer has made any payments on your claim.

Check this box if the insurer has not made any payments on your claim.

If the insurer has made payments, enter the type(s) of benefits paid (for example: medical bills, wage replacement, temporary disability) and any brief identifying details. Fill only if '22. Has the Insurer Made Any Payments On Your Claim? — Yes' is 'Yes'.

Enter the total dollar amount the insurer has paid toward the claim (include cents if applicable). Fill only if '22. Has the Insurer Made Any Payments On Your Claim? — Yes' is 'Yes'.

Check this box when you are claiming specific compensation under subsection (c) (i.e., you are asserting a specific monetary award) and will enter the amount in the adjacent space.

Enter the dollar amount being claimed for Specific Compensation under Section 30(c). Fill only if 'c. Specific Comp. in the Amount of $' is 'Yes'.

Check this box if you are claiming benefits under Section 34(a) for total temporary incapacity (total inability to work) for the date range(s) you will provide on the form.

Enter the starting date of the first period for which you are claiming total temporary incapacity benefits under Section 34(a). Fill only if 'Sec. 34 (a) Total Temporary Incapacity' is 'Yes'.

Enter the ending date of the first period for which you are claiming total temporary incapacity benefits under Section 34(a). Fill only if 'Sec. 34 (a) Total Temporary Incapacity' is 'Yes'.

Enter the starting date of the second period for which you are claiming total temporary incapacity benefits under Section 34(a), if applicable. Fill only if 'Sec. 34 (a) Total Temporary Incapacity' is 'Yes'.

Enter the ending date of the second period for which you are claiming total temporary incapacity benefits under Section 34(a), if applicable. Fill only if 'Sec. 34 (a) Total Temporary Incapacity' is 'Yes'.

Check this box if you are claiming partial incapacity benefits under Section 35 and will supply the applicable 'from' and 'to' date(s) for the benefit period.

Enter the starting date of the first Sec. 35(b) partial incapacity compensation period you are claiming. Fill only if 'Sec. 35 Partial Incapacity Comp. from (date):' is 'Yes'.

Enter the ending date of the first Sec. 35(b) partial incapacity compensation period you are claiming. Fill only if 'Sec. 35 Partial Incapacity Comp. from (date):' is 'Yes'.

Enter the starting date of the second Sec. 35(b) partial incapacity compensation period you are claiming. Fill only if 'Sec. 35 Partial Incapacity Comp. from (date):' is 'Yes'.

Enter the ending date of the second Sec. 35(b) partial incapacity compensation period you are claiming. Fill only if 'Sec. 35 Partial Incapacity Comp. from (date):' is 'Yes'.

Provide the employee's or claimant's full signature (handwritten or typed) to certify and authorize this claim.

Enter the date when the employee or claimant signed the form. Fill only if 'Employee/Claimant Signature' is filled.

Provide the attorney's full signature if an attorney represents the claimant; leave blank if not applicable. Fill only if 'Attorney - Name, Address & BBO#' is filled.

Enter the date when the attorney signed the form. Fill only if 'Attorney's Signature (if applicable)' is filled.

Enter the full name and mailing address (street, city, state, ZIP) of the medical facility where the employee was first treated for the injury.

Enter the full name (first and last) of the physician who treated the employee for the injury.

Enter the full name or names of the witness(es) associated with this claim (first and last names; include middle initial if desired).