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800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 http://www.mass.gov/dia Print Form EMPLOYEE S CLAIM FOR USE BY EMPLOYEES OR DEPENDENTS CLAIMING BENEFITS AS A RESULT OF INJURY OR DEATH. ALL OTHER CLAIMANTS SHOULD USE FORM 115 IMPORTANT - INSTRUCTIONS AND CODES ON THE REVERSE SIDE - Please Print Legibly or Type - Unreadable forms will be returned. 2. Social Security Number*: 3. Home Telephone No.: 4. Date of Birth: 1. Employee s Name (Last, First, MI): E M P L O Y E E.
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Siderosis FAQ
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Workers' Comp Exemptions in MA Sole-proprietors, partners, and limited liability company members with no employees are not required to purchase workers compensation coverage on themselves.
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To file a claim, download and complete Form 110 – Employee Claim. You will need 3 copies of this form and all other materials: 1 copy for the DIA. 1 copy for the workers' compensation carrier.
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✓ Once you apply for benefits, DUA contacts all the employers you listed on your claim and asks them for information regarding your past wages and the reason(s) you were separated. Each employer has 10 days to respond.
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All employers operating in Massachusetts are required to carry workers' compensation insurance for their employees and themselves if they are an employee of their company. The requirement applies no matter the number of hours worked or the number of employees.
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The Massachusetts Workers' Compensation Act requires you to cover all workers at all times, covering: Medical care for work-related injuries or illnesses. Partial wage replacement when your employees need time off to recover.
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The most that you can receive is the State's Average Weekly Wage (SAWW) at the time of your injury. The SAWW is set annually by the Massachusetts Division of Unemployment. You can receive these benefits for up to 156 weeks.
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What is the statute of limitations? Under the workers compensation law, (MGL c. 152, § 41) for injuries on or after January 1, 1986, a claim must be filed with the insurer within 4 years of the date you become aware of a connection between your injury/illness and your employment.
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It's illegal for an employer to discharge, demote, refuse to hire, or otherwise discriminate against an employee for collecting workers' compensation benefits or cooperating with a work accident inquiry.
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