Massachusetts Employees ClaimMassachusetts Employees Claim
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FORM 110

The Commonwealth of Massachusetts
Department of Industrial Accidents – Department 110

DIA Board #
(If Known):

1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470
http://www.mass.gov/dia

Print Form

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.
2. Social Security Number*: 3. Home Telephone No.: 4. Date of Birth:

1. Employee’s Name (Last, First, MI):
E
M
P
L
O
Y
E
E

E
M
P
L
O
Y
E
R

I
N
J
U
R
Y
I
N
F
O
R
M
A
T
I
O
N

6. Home Address (No., Street, City, State & Zip Code):

5. # of Dependents:

7. Employee’s E-mail address (if available): 7a . Employee’s Native
Language Code:
________

8. Name, Address and BBO# of Employee’s Attorney (if no attorney leave blank)**:

9. A