Form 110 - Employee'S Claim For Use By Employees Or Dependents Claiming Benefits As A Result Of Injury Or Death
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1
2FORM 110
The Commonwealth of Massachusetts
DIA Board #
Department of Industrial Accidents – Department 110
(If Known):
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
EMPLOYEE’S CLAIM
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.
1. Employee’s Name (Last, First, MI):
2. Social Security Number*:
3. Home Telephone No.:
4. Date of Birth:
5. # of Dependents:
E
7. Employee’s E-mail address (if available):
7a . Employee’s Native
M
6. Home Address (No., Street, City, State & Zip Code):
P
Language Code:
L
________
O
8. Name, Address and BBO# of Employee’s Attorney (if no attorney leave blank)**:
Y
E
E
9. Attorney’s E-mail address (Required):
9a. Attorney’s Telephone No.:
10. Employer’s Name & Address (No., Street, City, State & Zip Code):
E
10a. Industry Code (See Reverse Side):
M
P
L
O
11. Workers’ Compensation Insurance Carrier’s Address and Tel. No.
:
(NOT LOCAL AGENT/ADMINISTRATOR - See Instructions on reverse side)
Y
E
R
12a. Insurer’s Case/Claim #:
12. DATE OF INJURY (mm/dd/yyyy):
I
N
13. FIRST day of Total or Partial Incapacity to Earn Wages
14. FIFTH day of Total or Partial Incapacity to Earn Wages
J
(mm/dd/yyyy):
(mm/dd/yyyy):
U
15. If Employee has Died, Date of Death (mm/dd/yyyy):
16. Describe Injury (Lower Back..., leg..., arm... etc.):
R
Y
17. Briefly Describe How Injury/Exposure Occurred and Body Part(s) involved:
17a. Injury Code(s)
Body Part Code(s)
I
a.
to body part
a.
N
F
b.
to body part
b.
O
18. Name(s) of Witness(es):
R
c.
to body part
c.
M
19. Employee’s Regular Occupation:
21. Has Employee Returned to Work?:
20. Average Weekly Wage:
Actual
A
T
Yes
No
$_____________________
Estimated
I
22. Has the Insurer Made Any Payments On Your Claim?
Yes
No If Yes - Indicate Type of Benefits and Amounts (Medical Bills, Wages, etc.):
O
N
in the amount of $
§
§
23. Section(s) of Law Claimed. Check all appropriate boxes below and attach documentation as required by M.G.L. c 152,
7G,
10(1) and 452 CMR 1.07.
a. Sec. 34
Total, Temporary Incapacity Comp. from (date):
from
to
and
B
E
from
to
N
E
b. Sec. 35
Partial Incapacity Comp. from (date):
from
to
and
F
I
from
to
T
S
c. Sec. 36
Specific Comp. in the Amount of $
d. Sec. 31
Survivor’s Benefits e. Sec. 33
Burial Expenses f. Secs. 13 & 30
Medical Expenses g.
Other (Specify Sec):
C
L
24. Name and Address of Facility Where Employee was First Treated:
25. Name of Treating Physician:
A
I
26. Employee’s/Claimant’s Signature:
27. Date (mm/dd/yyyy):
M
E
D
Attorney’s Signature (if applicable
28
.
):
29. Date (mm/dd/yyyy):
-
*Disclosure of Social Security Number is Voluntary. It will aid in the processing of your claim.
Form 110
Revised 7/2013 - Reproduce as needed.
**Representation by an attorney is not required (see instructions on reverse side).
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