Claims Kit

Reporting of Claim by Employer  Chapter 152: Section 6

The employer or insurer must file sufficient notice of injury with the Department of Industrial Accidents (DIA). Notice is due in the form of an Employer's First Report of Injury or Fatality (Form 101). This is due within 7 calendar days (not including Sundays and legal holidays) from the worker's 5th full or partial day of disability.

All FROIs are submitted to DIA electronically. See Forms and Filing Instructions for further details.

Physician Selection  Chapter 152: Section 30  Chapter 152: Section 45

Except for the employee’s first scheduled appointment, which an employer may require to be with a health provider within their preferred provider arrangement, the worker has the right to choose their own healthcare professional for treatment. They are further permitted to change this elected physician once. 

When referred by the treating health care professional to another provider in a particular specialty, the employee may also change once to a different provider in that specialty. In cases of emergency or where the insurer or administrative judge agrees, the employee may seek treatment from additional providers

An employer may request, from time to time, that an employee submit to an examination during the continuance of his disability

Posting Requirements  Chapter 152: Section 21, Chapter 152: Section 22 Chapter 152: Section 30

The Department of Industrial Accidents (DIA) has revised the Notice to Employees poster (in English, in Spanish) and has established new notice requirements. On or before September 16, 2024, all employers must utilize and repost the revised Notice to Employees poster. All employers must:

• Fill out the Notice to Employees.
• Post the notice in a visible location utilized and accessible to all employees.
  • If no such location exists the poster must be distributed to employees electronically or by a mailed physical copy.
• Update, re-post, and re-distributed whenever any of the information changes.

Penalties for Late Reporting  Chapter 152: Section 6

Most claims must be reported to the Department of Industrial Accidents (DIA) within 7 calendar days--not including Sundays or legal holidays--from the 5th full or partial calendar day of disability. 

Any person who fails to provide satisfactory claim reporting notice three or more times in any year will incur a fine of $100 for each violation. Each failure to pay a fine within 30 days of receipt of a bill from the DIA will be considered a separate violation.

Electronic Form Filing May 11, 2020

In response to the COVID-19 pandemic and the Stay-Home Advisory implemented by Governor Baker, the Department has had to make modifications to our operating protocols. Effective May 26, 2020 we will require certain forms be completed on-line via our website and filed electronically. The implementation of online filing will ensure a more efficient workflow process as we continue to navigate the recommendations by federal and state officials as it relates to pandemic. Therefore, the DIA will no longer accept or process paper forms that are received via postal mail, facsimile or email attachment (*with exceptions noted below). Please be advised that the following forms are required to be completed on-line via our website and filed electronically going forward:
Form 101 Employer’s First Report of Injury
Form 103 Insurer’s Notification of Payment
Form 104 Insurer’s Notification of Denial
Form 106 Insurer’s Notification of Modification/Termination
Form 107 Insurer’s Notification of Modification/Termination/Resumption of Weekly Compensation During Pay W/O Prejudice Period
Form 108 Insurer’s Request for Discontinuance/Modification (*Supporting docs. must be faxed - see form instructions below)
Form 110 Employee’s Claim (*Supporting docs. must be faxed – see form instructions below)
Form 114 Attorney’s Appearance of Counsel
Form 115 Third Party Claim/Lien
Form 116 Request for Lump Sum Conference
*Form 108 & Form 110 attachments: Please be advised, claims for compensation and discontinuance requests must be accompanied by proper supporting documentation in accordance with M.G.L. c. 152, §7G & 452 CMR 1.07. When filing electronically, fax the additional documents to 617-727-4551 or email them to DIA-docattach@mass.gov. Each electronic filing is given a transmittal ID number you must reference when sending the attachments. Filing instructions are provided on the electronic forms. The above email address is for the attachments ONLY.
Also, we will issue notices, conference orders and decisions electronically. Attorneys and insurance carriers with CMS accounts have access to the required forms for electronic filing via the website. To access the online forms from your CMS calendar account, go to the calendar page and click on “online forms” on the top right side of the calendar. For online filing accounts (OLF/OLI) the link is located on the application tree on CMS.
We have added a field on the Form 110 to capture the injured worker’s email address. To check the status or make changes to your email address, please send an email to Francisco.Pena@mass.gov.

3/26/2020 - Submitting Documents to the Workers' Compensation Trust Fund

Effective immediately, all documents normally submitted to the Workers’ Compensation Trust Fund via U.S. mail should be submitted electronically in the manner specified below.With the exception of W-9 forms, which should be both emailed AND sent via U.S. mail and initial petitions for reimbursement pursuant to M.G.L. c. 152, section 37, which should be sent via U.S mail only, all submissions should be sent electronically as directed below:

Uninsured Claims Filed Pursuant to M.G.L. c. 152, 65:

• All documents relating to new cases or cases in which the assigned WCTF attorney is unknown should be emailed tolois.biswanger@mass.gov.

• All documents, except medical bills, related to existing cases should be emailed to the attorney assigned to the case, with a cc tolois.biswanger@mass.gov.

• All medical bills and supporting documentation should be emailed tolois.biswanger@mass.govOR faxed to the WCTF at (617) 727-6659.

• W-9 forms should continue to be submitted with original signatures via U.S. mail, with a copy emailed toarleen.cascio@mass.govand a cc tolois.biswanger@mass.gov.

Petitions for Reimbursement Pursuant to M.G.L. c. 152 and Quarterly Submissions

All initial petitions for reimbursement should continue to be sent via U.S. mail,

• All requests for quarterly reimbursement should be sent electronically toclarissa.cutts@mass.gov,with a cc tolois.biswanger@mass.gov

All Other Mail

All other mail should be sent electronically tolois.biswanger@mass.gov

Except as noted above, please send submissions solely through electronic mail and do not mail “hard copies” to the office.