This government document is issued by Department of Industrial Accidents (DIA) for use in Massachusetts
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PDF
(185 KB)
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https://www.mass.gov/doc/form-170-affidavit-of-employee-in-application-for-trust-fund-benefits/download?_ga=2.24927930.1854129817.1751542062-2000327536.1747311789&_gl=1*5736ik*_ga*MjAwMDMyNzUzNi4xNzQ3MzExNzg5*_ga_MCLPEGW7WM*czE3NTE1NDIwNjIkbzY4JGcxJHQxNzUxNTQyODg4JGo2MCRsMCRoMA..