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

41 - 60 of 61 forms

Form Title Topics
Form 132: Affidavit in Support of Employee's Request for Speedy Conference Because of Hardship
Form 133A: Utilization Review (UR) Agent Complaint
Form 134: Health Care Provider Complaint
Form 136 - Affidavit of Indigence and Request for Waiver of § 11A(2) Fees
Form 140 - Conference Memorandum
Form 141 - Last Best Offer
Form 151: Individual Written Rehabilitation Program Form
Form 152: Amendment/Suspension or Closure of Vocational Rehabilitation Plan
Form 154 - Verification of Workers' Compensation Coverage by Out-of-State Employers Operating in Massachusetts
Form 160: Employee's Biographical Data Sheet
Form 161: Employee's Hearing Memorandum
Form 162: Insurer's Hearing Memorandum
Form 170: Affidavit of Employee in Application for Trust Fund Benefits
Form 19: Section 19 Agreement
Form 50 template
Form 51 template
Form CR-28: Massachusetts Workers' Compensation COLA Data Form
Forms that MUST be filed via an online account
FY25 Standard Contract
Insurance Certification Request Form

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