The Commonwealth of Massachusetts
FORM 112
DIA Board #
Department of Industrial Accidents – Department 112
(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
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
INSTRUCTIONS ON REVERSE SIDE
1. Party Filing this Form is:
Insurer
Employee
Other (please specify) _______________________
2. Date of Decision (mm/dd/yyyy
:
3. Name of Judge Who Issued Hearing Decision:
4. Date of Injury (mm/dd/yyyy):
)
5. Employee’s Name (Last, First, MI
6. Employee’s Social Security Number*:
:
)
7. Employee’s Address (No. and Street, City, State, Zip Code):
8. Employee’s Telephone Number:
C
A
S
9. Employer’s Name & Address (No. and Street, City, State, Zip Code):
E
I
N
10. Name of Workers’ Compensation Insurance Carrier:
F
O
R
11. Name of Insurer’s Attorney:
M
12. Attorney’s Telephone Number:
A
T
I
13. Address of Insurer’s Attorney (No. and Street, City, State, Zip Code):
O
N
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
§
17. Briefly set out the basis for the appeal under M.G.L. c. 152,
11C:
R
O
U
N
D
S
18. Check Where Applicable:
A.
Filing Fee Attached.
B.
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.
C.
Request Verbatim Transcript.
D.
Verbatim Transcript Waived.
19. Preparer’s Name & Address (Please Print or Type):
20. Preparer’s Telephone Number
21. Preparer’s Signature (“On-File” is NOT acceptable. Must have signature.):
22. Date Prepared (mm/dd/yyyy):
-
*Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents.
Form 112
Revised 7/2013 - Reproduce as needed.
Please Print Clearly or Type. Unreadable forms will be returned.