Department of Industrial Accidents (DIA)

State of Massachusetts

Official Website: https://www.mass.gov/orgs/department-of-industrial-accidents

Forms & Documents

Browse all Department of Industrial Accidents (DIA) government forms

1 - 20 of 61 forms

Form Title Topics
2025 MHSA Registration Form
Administrative Bulletin #4 - Online Filing
Administrative Bulletin #4 - Online Filing
Administrative Bulletin - Submission of Forms 105 and 103 going forward
AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORATE OFFICERS OR DIRECTORS
Affidavits for Builders, Contractors, Plumbers, and Electricians
Application To Become An Approved Utilization Review Agent and Affidavit of Compliance Forms
Bond Form
C. L. 215 - New Claim Form Replacing Form 17 and Form 31
C. L. 226 - Publication of New Departmental Forms
C. L. 269: New Forms
C. L. 294 - Updated Forms and Requirements for s.s. 37/37A Claims
C. L. 307 - New DIA Forms
CL 343 - Conversion To Electronic Filing For All First Reports Of Injury By Jan. 1, 2014
C. L. 94: Emergency Room's First Report of Injury - Standard Form
COLA Offset - General Guidelines for Insurers
Directions Form 110: Employee Claim / English
Directions Form 110: Employee Claim / Spanish
Form 105 - Agreement to Extend 180 Day Payment-Without-Prejudice Period
Form 109 - Notification of Withdrawal of Claim or Complaint

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