Employees Claim With Filing Instructions Form. This is a Massachusetts form and can be use in Workers Comp.
Tags: Employees Claim With Filing Instructions, 110, Massachusetts Workers Comp,
The Commonwealth of Massachusetts Department of Industrial Accidents Department 110 Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111 - 1750 Info. Line (800) 323 - 3249 Inside Mass. / (857) 321 - 7470 Outside Mass. www.mass.gov/dia FOR USE BY EMPLOYEES OR DEPENDENTS CLAIMING BENEFITS AS A RESULT OF INJURY OR DEATH. ALL OTHER CLAIMANTS SHOULD USE FORM 115 IMPORTANT - INSTRUCTIONS AND CODES ON THE REVERSE SIDE - Please Print Legibly or Type - Unreadable forms will be returned. FORM 110 Form 110 - Revised 7/2019 - Reproduce as needed. 3. Home Telephone No.: 6. Home Address (No., Street, City, State & Zip Code): - mail address (if available): (NOT LOCAL AGENT/ADMINISTRATOR - See Instructions on reverse side) : 12. DATE OF INJURY (mm/dd/yyyy): 13. FIRST day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy): 17. Briefly Describe How Injury/Exposure Occurred and Body Part(s) involved: 5. # of Dependents: E M P L O Y E E 2. Social Security Number*: 4. Date of Birth: E M P L O Y E R 10a. Industry Code (See Reverse Side): I N J U R Y I N F O R M A T I O N 15. If Employee has Died, Date of Death (mm/dd/yyyy): 14. FIFTH day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy): 20. Average Weekly Wage: Actual $ Estimated 21. Has Employee Returned to Work?: Yes No 17a. Injury Code(s) a. to body part b. to body part c. to body part Body Part Code(s) a. b. c. 22. Has the Insurer Made Any Payments On Your Claim? Yes No If Yes - Indicate Type of Benefits and Amounts (Medical Bills, Wages, etc.): in the amount of $ 25. Name of Treating Physician: 27. Date (mm/dd/yyyy): 28 . ): 29. Date (mm/dd/yyyy): *Disclosure of Social Security Number is Voluntary. It will aid in the processing of your claim. **Representation by an attorney is not required (see instructions on reverse side). 16. Describe Injury (Lower Back..., leg..., arm... etc.): 23. Section(s) of Law Claimed. Check all appropriate boxes below and attach documentation as required by M.G.L. c 152, 247 7G, 247 10(1) and 452 CMR 1.07. a. Sec. 34 Total, Temporary Incapacity Comp. from (date): from to and from to b. Sec. 35 Partial Incapacity Comp. from (date): from to and from to c. Sec. 36 Specific Comp. in the Amount of $ d. e. Sec. 33 Burial Expenses f. Secs. 13 & 30 Medical Expenses g. Other (Specify Sec): 24. Name and Address of Facility Where Employee was First Treated: B E N E F I T S C L A I M E D 18. Name(s) of Witness(es): - mail address (Required): DIA Board # (If Known): Language Code: American LegalNet, Inc. www.FormsWorkFlow.com 1 . WHEN TO FILE : File this form if you have been injured on the job and your compensation insurer (the insurer) has denied your initial claim and/or is disputing any part of your claim and refuses to pay the compensation that you believe you are entitled . Please fill out the form completely and accurately . The Department of Industrial Accidents (DIA) is the agency that handles all disputed compensation claims . You do not need to be represented by an attorney in order to file a Form 110 . You may represent yourself in your claim . The term that applies to self representation is PRO SE . Initiating a claim PRO SE does not prevent you from getting an attorney later . If you need assistance, please call 1 - 800 - 323 - 3249 inside Massachusetts, or ( 857 ) 321 - 2149 outside Massachusetts . 2 . WHERE TO FILE : The original form must be mailed to the DIA at the address shown on the front of the form . A copy must also be provided to the employer as well as the insurer . We recommend that the employee keep a third copy for their own records . When an employee is represented by counsel, this form must be sent via certified mail to the insurer . Please be advised - claims for compensation must be accompanied by proper documentation in accordance with M . G . L . c . 152 , 247 7 G & 452 CMR 1 . 07 . 3 . REQUIREMENTS : The law requires that all employers in Massachusetts carry a valid compensation insurance policy at all times for all of their employees in the event of an industrial injury . Also, the employer must provide the name and address of the compensation insurer upon request of an employee . If the employer refuses to provide this information or does not carry compensation insurance, notify the DIA immediately . 4 . SIGNATURE & DATE IN BOXES 26 & 27 : This form may be filed by the Employee or the Attorney (if applicable) . However, in all cases the Employee must sign and date this form . Agriculture, Forestry and Fishing 01 Agriculture Production - Crops 02 Agriculture Production - Livestock 07 Agricultural Services 08 Forestry 09 Fishing, Hunting and Trapping Mining 10 Metal Mining 12 Coal Mining 13 Oil and Natural Gas 14 Nonmetallic Minerals, Except Fuels Construction 15 General Building Contractors 16 Heavy Construction, Ex. Building 17 Special Trade Contractors Manufacturing 20 Food and Kindred Products 21 Tobacco Products 22 Textile Mill Products 23 Apparel and Other Textile Products 24 Lumber and Wood Products 25 Furniture and Fixtures 26 Paper and Allied Products 27 Printing and Publishing 28 Chemicals and Allied Products 29 Petroleum and Coal Products 30 Rubber and Misc. Plastic Products 31 Leather and Leather Products 32 Stone, Clay and Glass Products 33 Primary Metal Industries 34 Fabricated Metal Products 35 Industrial Machinery and Equipment 36 Electronic and Other Electrical Equipment 37 Transportation Equipment 38 Instruments and Related Products 39 Miscellaneous Manufacturing Industries Transportation and Public Utilities 40 Railroad Transportation 41 Local and Interurban Passenger Transit 42 Trucking and Warehousing 43 U.S. Postal Service 44 Water Transportation 45 Transportation by Air 46 Pipelines, Except Natural Gas 47 Transportation Services 48 Communications 49 Electric, Gas and Sanitary Services Wholesale Trade 50 Wholesale Trade - Durable Goods 51 Wholesale Trade - Non - durable Goods Retail Trade 52 Building Materials and Garden Supplies 53 General Merchandizing 54 Food Stores 55 Automotive Dealers and Service Stations 56 Apparel and Accessory Stores 57 Furniture and Home Furnishing Stores 58 Eating and Drinking Establishments 59 Miscellaneous Retail Finance, Insurance and Real Estate 60 Depository Institutions 61 Non - depository Institutions 62 Security and Commodity Brokers 63 Insurance Carriers 64 Insurance Agents, Brokers and Service 65 Real Estate 67 Holding and Other Investment Officers Services 70 Hotels and Other Lodging Places 72 Personal Services 73 Business Services 75 Auto Repair Services and Parking 76 Miscellaneous Repair Services 78 Motion Pictures 79 Amusements and Recreation Services 80 Health Services 81 Legal Services 82 Educational Services 83 Social Services 84 Museums, Botanical, Zoological Gardens 86 Membership Organizations 87 Engineering and Management Services 88 Private Households 89 Services, NEC Public Administration 91 Executive, Legislative and Garden 92 Justice, Public Order, and Safety 93 Finance, Taxation, and Monetary Benefits 94 Administration of Human Services 95 Environmental Quality and Housing 96 Administration of Economic Program 97 National Security and International Affairs Non - classifiable Establishments 99 Non - classifiable Establishments NATURE OF INJURY OR ILLNESS CODES 100 Amputation or Enucleation 110 Asphyxia or Strangulation Etc. 120 Burns (Heat) 130 Burns (Chemical) 140 Concussion 160 Contusion, Crushing, Bruise 170 Cut, Laceration, Puncture 190 Dislocation 200 Electric Shock, Electrocution 210 Fracture 250 Hernia, Rupture 300 Scratches, Abrasions 310 Sprains, Strains 400 Multiple Injuries 900 No Injury 950 Damage to Prosthetic Devices 995 No Other Injury, NEC** 999 Non - classifiable Infective or Parasitic Disease 150 Infective or Parasitic Disease, UNS* 151 Amebiasis 152 Anthrax 153 Brucellosis 154 Conjunctivitis and Opthalmia 156 Tetanus BODY PART AFFECTED CODES 157 Tuberculosis 159 Other Infective or Parasitic Diseases Dermatitis 180 Dermatitis, UNS* 183 Primary Infections of the Skin 184 Other Skin Conditions 185 Dermatitis, Allergenic or Contact 189 Skin Condition, NEC** Poisoning Systemic 270 Poisoning, Systemic, UNS* 271 Due to Toxic Materials other t