Get Dia Form 110

Navigating the filing process for the Dia Form 110 can be straightforward with the right guidance. This form is essential for employees or dependents seeking benefits due to an injury or death related to work. By following these detailed instructions, you will ensure that your claim is submitted correctly and efficiently.

Follow the steps to fill out the Dia Form 110 online.

1. Press the ‘Get Form’ button to access the Dia Form 110. This will allow you to open the form in your preferred online editing tool.
2. Begin by entering the employee's name in the designated fields. Please include the last name, first name, and middle initial if applicable.
3. Input the social security number in the provided field. This information, while voluntary, can help expedite the processing of your claim.
4. Enter the home telephone number and date of birth of the employee in the respective fields.
5. List the number of dependents, followed by the employee's email address if available and the native language code corresponding to the employee's first language.
6. Detail the home address thoroughly including the number, street, city, state, and zip code.
7. If applicable, provide the name, address, and BBO number of the employee's attorney. If there is no attorney, leave this section blank.
8. Insert the attorney's email address and telephone number if an attorney is representing the claim.
9. State the employer's name and their complete address, including the number, street, city, state, and zip code.
10. Complete the industry code by selecting the appropriate code from the provided list based on the type of work the employee was engaged in at the time of injury.
11. Identify the workers' compensation insurance carrier’s address and telephone number, making sure not to provide the local agent's details.
12. Enter the date of injury using the format mm/dd/yyyy.
13. Indicate the first day of total or partial incapacity to earn wages.
14. Provide the date of the fifth day of total or partial incapacity to earn wages.
15. If applicable, include the date of death of the employee.
16. Describe the nature of the injury, specifying which body parts were affected.
17. Briefly explain how the injury or exposure occurred, including the body parts involved.
18. List the names of any witnesses who can support the claim.
19. Describe the employee's regular occupation.
20. Enter the average weekly wage before the injury.
21. Respond to whether the insurer has made any payments on the claim.
22. Indicate if the employee has returned to work, providing details about type of benefits and amounts if applicable.
23. Check the relevant sections of law claimed, and attach any necessary documentation as specified.
24. Fill out the name and address of the facility where the employee was first treated.
25. Provide the name of the treating physician.
26. Ensure the employee or their attorney signs and dates the form in the designated fields.

Complete your Dia Form 110 online today to ensure your claim is filed promptly and accurately.