DIA FILE REQUEST Please fill out this information as fully as possible. TO: The Keeper of Records Dept. of Industrial Accidents 1 Congress St., Suite 100 Boston, MA 02114-2017 Requesting Party: ____ Injured Worker/Employee ____ Employee's Counsel: ____ Current or ____ Former ____ Insurer's Counsel ____ 3rd Party Representative: ___________________________________ (Name of 3rd Party) ____ Other: __________________________________________________ (Please Specify) PLEASE NOTE: If you are not listed in our records as a party to the case you wish to view and/or obtain copies of documents from, we will need a signed authorization from the Employee. Name of Requester: ______________________________________________ Address of Requester: ______________________________________________ ______________________________________________ Telephone Number: Date Requested _________________________ _________________________ Employee Name: _________________________________________________ Address: _______________________________________________________ _______________________________________________________ Soc. Sec. # (if known): ____________________________________________ Date(s) of Injury: _______________________________________________ DIA #(s) (if known): _______________________________________________ Employer(s): ____________________________________________________ Workers' Comp. Insurer: ___________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com DIA FILE REQUEST ­ p. 2 Please add any additional information you may have that will help us in locating the file. I Am Requesting: ____ Access to view the workers' compensation record(s) (Please be advised that after viewing a file, it may not be possible to obtain file copies the same day) ____ A copy of the entire file(s) ____ A copy of the Lump Sum Settlement ____ A copy of a specific form/document, i.e., Employer's First Report of Injury , Employee's Claim, Agreement to Pay Compensation, Conference Order, Hearing Decision, etc. _______________________________________________ (Specify Form/Document) (v.07/19/10) American LegalNet, Inc. www.FormsWorkFlow.com