FORM 112 The Commonwealth of Massachusetts Department of Industrial Accidents ­ Department 112 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 Info. Line 800-323-3249 ext. 7470 in Mass. Outside Mass. - 617-727-4900 ext. 7470 http://www.mass.gov/dia DIA Board # (If Known): APPEAL TO REVIEWING BOARD THIS FORM IS TO BE FILED WHEN EITHER PARTY SEEKS TO APPEAL THE HEARING DECISION OF AN ADMINISTRATIVE JUDGE ON LEGAL GROUNDS. Please Print or Type 1. Party Filing this Form is: INSTRUCTIONS ON REVERSE SIDE Insurer Employee Other (please specify) _______________________ 4. Date of Injury (mm/dd/yyyy): 6. Employee's Social Security Number*: 2. Date of Decision (mm/dd/yyyy): 5. Employee's Name (Last, First, MI): 3. Name of Judge Who Issued Hearing Decision: 7. Employee's Address (No. and Street, City, State, Zip Code): C A S E I N F O R M A T I O N 8. Employee's Telephone Number: 9. Employer's Name & Address (No. and Street, City, State, Zip Code): 10. Name of Workers' Compensation Insurance Carrier: 11. Name of Insurer's Attorney: 12. Attorney's Telephone Number: 13. Address of Insurer's Attorney (No. and Street, City, State, Zip Code): 14. Name of Employee's Attorney: 15. Attorney's Telephone Number: 16. Address of Employee's Attorney (No. and Street, City, State, Zip Code): G R O U N D S 17. Briefly set out the basis for the appeal under M.G.L. c. 152, §11C: 18. Check Where Applicable: A. B. C. D. Filing Fee Attached. Request for Waiver of Filing Fee based upon indigence. Affidavit in Support of Waiver of Filing Fee must be submitted before your appeal will be docketed. Request Verbatim Transcript. Verbatim Transcript Waived. 20. Preparer's Telephone Number 19. Preparer's Name & Address (Please Print or Type): 21. Preparer's Signature ("On-File" is NOT acceptable. Must have signature.): 22. Date Prepared (mm/dd/yyyy): Form 112 - Revised 7/2013 - Reproduce as needed. *Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents. Please Print Clearly or Type. Unreadable forms will be returned. American LegalNet, Inc. www.FormsWorkFlow.com APPEAL TO REVIEWING BOARD FILING INSTRUCTIONS 1. WHEN TO FILE: File Form 112 the Department of Industrial Accidents within thirty (30) days from the date of a hearing decision by an Administrative Judge along with the requisite filing fee. This form is not to be used to appeal a conference order issued by an Administrative Judge. Please Use Form 121 for that purpose. 2. WHERE TO FILE: Reviewing Board Appeals Department of Industrial Accidents 1 Congress St., Suite 100 Boston, MA 02114-2017 3. FILING FEES: There is no filing fee for injuries occurring prior to November 1, 1986. For injuries after November 1, 1986, this form must be accompanied by a fee of thirty (30) percent of the average weekly wage in the Commonwealth at the time of the appeal, unless the fee is waived by the Reviewing Board due to indigence. Please make checks payable to "Massachusetts Industrial Accidents Special Fund" and forward to the above address. If you are unable to pay the filing fee and wish to have it waived, you must submit an Affidavit in Support of Waiver of Filing Fee. This affidavit must be submitted before the case can be docketed. 4. A copy of the Administrative Judge's decision must be attached to this appeal. American LegalNet, Inc. www.FormsWorkFlow.com