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Work injury claim form

Work-related injuries or illnesses often result in lost work time, which can make it difficult to stay afloat financially. Workers’ compensation benefits are available to eligible Commonwealth residents to provide some financial assistance until they are able to return to work.

About Workers’ Compensation

Workers’ compensation is administered by the Massachusetts Department of Industrial Accidents (DIA). Both injured workers and employers may contact the DIA for finding insurers and attorneys to help with a workers’ case. The DIA also includes a court system that resolves disputed workers’ compensation claims.

Applying for Workers’ Compensation

In order to apply for workers’ compensation, the Employer’s First Report of Injury or Fatality – Form 101 must be filled with the DIA as well as the workers’ compensation insurance company within seven days. From there, the insurance company has fourteen days from when they receive this form from an employer to investigate the claim and make a decision to pay the claim or not.

Types of Benefits

There are a number of workers’ compensation benefits for which claimants may be eligible:

  • Temporary Total Incapacity Benefits – These can be received for a maximum of 156 weeks and account for 60 percent of the gross average weekly wage. Qualified individuals must have a work-related injury or illness that causes them to be unable to work for six or more calendar days.
  • Partial Incapacity Benefits– These are available to those who can still work, but who lose partial earnings due to injury or illness. The maximum compensation is limited to 75 percent of weekly total temporary benefits and can be received for a maximum of 260 weeks.
  • Permanent and Total Incapacity Benefits – These can be received for as long as the individual is disabled or totally and permanently unable to work. Two-thirds of the average weekly wage will be granted based on the 52 weeks prior to injury.
  • Medical Benefits – These can be claimed as long as medical and hospital services are required due to work-related injury or illness. Medical charges and mileage may also be reimbursed. Benefits may be received for as long as medical and hospital services are required due to injury or illness.
  • Permanent Loss of Function and Disfigurement Benefits – These are available to those who have a work-related injury or illness that resulted in the loss of specific bodily functions. A one-time payment will be made depending on the location and severity of function loss.

The Commonwealth of Massachusetts and the DIA are committed to helping those in need by offering a wide variety of benefits to help ill and injured employees in the Commonwealth while they are out of work recovering. Share these resources with friends and family who may be in need of assistance.

Please feel free to comment below or tweet us @MassGov.

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