How to Fill Out a Massachusetts DIA Conciliation Request (With Examples) + FAQs

In Massachusetts, you start a workers’ compensation conciliation by filing Form 110 – Employee Claim with the Department of Industrial Accidents (DIA), and that single filing is what triggers your conciliation date. There is no separate “conciliation request” form. When you mail or hand in a complete Form 110, the DIA automatically schedules a conciliation, the informal first step where you and the insurer try to settle your dispute.

This matters because a small slip on the form can cost you weeks. The DIA’s own guidance says most claims get rejected for the same three reasons: the wrong insurance carrier, no checked benefit boxes, and a missing 1st and 5th day of disability, as the DIA explains in its file a claim guide. Each rejection bounces your paperwork back and delays the help you need while you are hurt and out of work.

This guide walks you through every box on the current Form 110 (Revised 7/2018), step by step, in plain language. Here is what you will learn:

• 📋 What Form 110 is, who must file it, and why it starts your conciliation
• 🗂️ The exact documents and ID numbers to gather before you write a single line
• ✍️ A box-by-box walkthrough with real sample entries you can copy
• 👥 Three full filled-out examples for the most common injury situations
• ⚖️ The mistakes that get claims rejected and how to dodge every one

What Form 110 Is and Who Must File It

Form 110 – Employee Claim is the official document an injured worker uses to ask for a judicial proceeding at the DIA when they believe they are not getting all the workers’ compensation benefits the law allows. You can download the current version, the Form 110 Employee Claim, directly from the DIA. The DIA’s directions sheet states plainly that the only reason to complete this form is to request a proceeding before an Administrative Judge to obtain benefits, per the official Form 110 directions.

You file this form when one of three things happens: your insurer denies your claim, your employer refuses to file a claim, or 30 or more calendar days have passed since your injury with no benefits. The agency that receives the form is the DIA, and the law that governs the whole system is Massachusetts General Laws Chapter 152, the state workers’ compensation act. The required documents you must attach come from the regulation 452 CMR 1.07, and skipping them gets your claim thrown out.

The form connects to a larger four-level dispute process. Level one is conciliation, an informal meeting; level two is a conference before an Administrative Judge; level three is a formal hearing; and level four is review by the Reviewing Board, as laid out in the DIA’s dispute resolution steps. Form 110 is the key that unlocks level one. Without it, none of the later steps can begin.

Most filers are injured workers acting on their own, often called pro se filers. If you have a lawyer, your attorney must file Form 110 through their online DIA account, but unrepresented workers mail or hand-deliver a paper form. The DIA does recommend hiring an attorney for a conciliation, yet thousands of workers file on their own each year, which is why this guide is built for you.

Before You Start: Documents and Information You Need

Gathering your facts before you open the form is the single best way to avoid a rejection. The DIA tells filers exactly what to know before filing, and missing any one item can stall your case. Pull these together first, because the form asks for each in a specific box.

• Your date of injury or illness. This anchors your whole claim; without it the DIA cannot confirm you filed within the statute of limitations under Chapter 152.
• The 1st calendar day of work you missed. This sets when your lost-wage period begins; leaving it blank is a top reason claims get rejected.
• The 5th calendar day of work you missed. Massachusetts pays weekly benefits only after a waiting period, so this date proves you cleared it.
• The workers’ compensation insurance carrier. The DIA cannot schedule a conciliation without the correct carrier name, so guessing the wrong one halts everything.
• The body parts and types of injury. These match code numbers on the back of the form, and mismatched codes confuse processing.
• The benefits you want. You must check the right sections of the law, or the DIA rejects the form for having no benefits claimed.
• Where you first got treatment and your current doctor. These tie your injury to real medical care and support your claim at conciliation.
• At least one supporting document. You must attach an unpaid medical bill, a medical report, an accident report, or a witness statement, or the form is rejected on sight.

To find your carrier when you do not know it, check any insurer letter, especially the Form 104 – Notification of Denial, or call the DIA Office of Insurance at (617) 626-5481, as the DIA suggests in its file a claim instructions. If your employer had no insurance on your injury date, you file against the Workers’ Compensation Trust Fund instead. Bring the rest of your records, the bills and reports you do not attach, to the conciliation itself, because the conciliator may ask to see them.

Where to Get the Form and How to Access It

You get Form 110 straight from the DIA website, and using the current revision matters because older versions can have different box numbers. Download the official Form 110 Employee Claim PDF, which is the 7/2018 revision printed in the bottom corner. Confirm that date before you start so you know you have the right version.

You can also find it on the DIA numerical form list, where every DIA form is organized by number. The PDF is fillable on a computer, or you can print it and write by hand in dark ink. Either way works for a paper filer, but typing reduces the risk that the DIA cannot read your entries.

Pair the form with its plain-language helper, the official Form 110 directions, which explains the key boxes and lists the native-language and industry codes printed on the back. If you have questions while filling it out, the DIA runs a toll-free hotline in Massachusetts at 1-800-323-3249, open Monday through Friday, 8 a.m. to 5 p.m. Calling before you mail is far cheaper than fixing a rejection after.

If English is not your first language, the form supports native-language codes so the DIA knows how to communicate with you. The agency also offers help by phone and at its regional offices. Taking a few minutes to read the directions sheet alongside the form prevents most of the errors that send claims back.

Step-by-Step: How to Fill Out Form 110 Line by Line

This is the heart of the form. Fill in as many boxes as you can, but the ones below are the ones the DIA says matter most for fast processing. Use the exact box numbers printed on the official form, and write sample entries in dark, clear print.

Box #1: Employee Name (Last, First, Middle Initial)

This box asks for your full legal name, the name you go by on official records. Print or type your last name, then first name, then middle initial, in that order. For example, Rivera, Carlos M. is how Carlos, a warehouse worker, fills it in. Use the name on your Social Security card so the DIA can match your records.

A common edge case is a recent name change after marriage or divorce. If your medical bills still show your old name, list your current legal name here and be ready to explain the difference at conciliation. A frequent mistake is writing a nickname like “Carlos” alone with no last name, which makes it hard to match your file and slows processing. Many filers wrongly believe the order does not matter, but the form is read last-name-first, so reversing it can misfile your claim.

Box #2: Social Security Number

This box asks for your nine-digit Social Security number. Print it in the standard format, for example 123-45-6789. Maria Lopez, a hotel housekeeper, writes her full nine digits here.

The DIA directions note that giving your number is voluntary, but it helps the agency keep your file separate from others with the same name. If you leave it blank and another worker shares your name, your notices could get mixed up. A common mistake is transposing two digits, which can attach your claim to the wrong record. Some people fear identity theft and skip it entirely, but the DIA uses it only to keep records straight, not to share it.

Box #3: Home Telephone Number

This box asks for your home or main phone number. Print the area code and number, for example (508) 555-0142. Carlos enters his cell number here since he has no landline.

Use a number you actually answer, because the DIA or the conciliator may call about your date. If you only have a cell phone, that is fine; the box just needs a working number. A common mistake is listing a disconnected number, which means you miss calls about scheduling. People sometimes think the DIA only writes letters, but a quick phone call can fix a small problem before it becomes a rejection.

Box #4: Date of Birth

This box asks for the day you were born. Print it in month, day, year order, for example 03/14/1985. Maria writes 07/22/1979 in her box.

Your birth date helps confirm your identity and ties to your dependent count and benefit math. A common edge case is a typo that makes you appear underage or far older, which can flag your file for review. The frequent mistake here is using a foreign date format, day first, which scrambles the entry. Some filers think this box is optional, but it helps the DIA confirm you are the right person on the claim.

Box #5: Number of Dependents

This box asks how many people depend on you for support, such as a spouse or children. Print the number, for example 2. Carlos, who supports his wife and one child, writes 2.

Dependents can affect certain benefit amounts, so an accurate count matters. A common edge case is a child who turns 18 during your claim; list your dependents as of your injury date and note changes later. A frequent mistake is leaving it blank, which the DIA may read as zero and undercount your household. Many people think dependents include roommates, but it means those you legally support, like a spouse or minor child.

Box #6: Full Home Address

This box asks for your complete home address. Print your street, city, state, and ZIP, for example 45 Oak Street, Worcester, MA 01605. Maria enters her full address here.

This box is critical because all notices, orders, and decisions go to this address. If it is wrong, you may miss your conciliation date entirely. A common edge case is using a P.O. Box; if you do, also be ready to give a physical address, since your conciliation is scheduled at the office nearest your home. The big mistake is an outdated address after a move, which sends your hearing notice to the wrong place. Some people assume email is enough, but the DIA confirms notices still go by regular mail.

Box #7 and #7a: Email and Native Language

Box #7 asks for your email, which is optional, and Box #7a asks for your native language if English is not your first language. For Box #7, print your email, for example carlos.rivera@email.com. For Box #7a, use the native-language code from the back of the form.

Providing email helps, but the DIA confirms your official notices still arrive by postal mail. The edge case for Box #7a is a worker more comfortable in Spanish, who enters the matching code so the DIA can help in that language. A common mistake is assuming email replaces mail, then missing a mailed notice. People often skip Box #7a out of pride, but listing your language gets you better help, not less.

Box #10 and #10a: Employer Name, Address, and Industry Code

Box #10 asks for your employer’s business name and address, and Box #10a asks for the industry code. Print your employer’s legal business name and main office address in Box #10, for example Bay State Logistics Inc., 200 Commerce Way, Springfield, MA 01089. For Box #10a, use the industry code from the back of the form, or write 99 if you cannot find one.

If your company has several locations, use the business office address, not your worksite. The edge case is a staffing agency; list the agency that pays you, and mention the host worksite at conciliation. A common mistake is naming your supervisor instead of the company, which misidentifies the employer. People often think the industry code is hard, but the DIA lets you simply enter 99 when unsure.

Box #11: Workers’ Compensation Insurance Carrier

This box asks for the name of the insurance company that pays your benefits, not the agent. Print the carrier’s full name, for example Liberty Mutual Insurance Company. Carlos finds the carrier on a denial letter and enters it exactly.

The DIA states it cannot schedule a conciliation without this information, so this box is make-or-break. The edge case is when your employer will not tell you; call the DIA Office of Insurance at (617) 626-5480 or check any insurer form, especially the Form 104 – Notification of Denial. The most common rejection cause statewide is the wrong carrier, so a guess that names the agent or a parent company stops your claim cold. Many filers confuse the insurance agent or broker with the carrier, but only the carrier name belongs here.

Box #12 and #12a: Date of Injury and Insurer Claim Number

Box #12 asks for the date you were first hurt or became ill from work, and Box #12a asks for the claim number the insurer assigned. Print the injury date in MM/DD/YYYY, for example 01/15/2026. If you are unsure, the DIA says use the date you first got treatment or your last day worked.

For Box #12a, print the insurer’s case or claim number if you have one; it speeds matching but is not always available. The edge case is a repetitive-strain injury with no single date; use the day you first got medical care. A common mistake is leaving Box #12 blank, which can make the DIA question whether you filed within the time limits under Chapter 152. People often skip Box #12a thinking it is required, but you can leave it blank if the insurer never gave you a number.

Box #13 and #14: First and Fifth Day of Disability

Box #13 asks for the first day you could not earn full wages because of your injury, and Box #14 asks for the fifth such day. Print each in MM/DD/YYYY, for example Box #13 as 01/16/2026 and Box #14 as 01/22/2026. Maria counts calendar days she missed full pay and enters both.

These two dates are essential because Massachusetts pays weekly benefits only after a five-day waiting period. The edge case is intermittent missed days; count the calendar days you could not earn full wages, not only consecutive ones. Leaving these blank is one of the top three rejection reasons the DIA names, so never skip them. People often confuse the date of injury with the first day of disability, but you can be hurt one day and stay on the job until pain forces you out later.

Box #17a: Nature of Injury and Body Part Codes

This box asks for the type of injury and the body part affected, using codes from the back of the form. Print the matching code pairs, for example a. 300 (sprain), a. 210 (back), keeping each injury aligned with its body part. Carlos lists his back strain using the code pair from the form’s back page.

You can list more than one injury, but the directions stress that the injury in line “a” must match the body part in line “a,” and so on. The edge case is multiple injuries from one accident; use separate lettered lines so each pair stays matched. A common mistake is crossing the codes, listing a back code with a hand injury, which confuses the medical picture. People think they must describe the injury in words, but the form wants the codes from the back page.

Box #23: Benefits Being Claimed

This box asks which benefits you believe the law owes you, listed by section of Chapter 152. Check every box that applies, for example Section 34 for total incapacity, Section 30 for medical bills, or Section 35 for partial incapacity. Maria checks Section 34 and Section 30 because she is fully out of work with unpaid bills.

Other listed sections include Section 28 for willful misconduct by the employer, Section 7 for penalties and interest, and more. The edge case is a worker unsure which benefit fits; check medical (Section 30) plus the wage benefit that matches your situation, and confirm at conciliation. Failing to check any box is a top-three rejection reason, since the DIA cannot tell what you want. People wrongly think one checkbox covers everything, but each section is a separate benefit you must claim on purpose.

Box #26 and #27: Signature and Date

Box #26 asks for your signature, and Box #27 asks for the date you sign. Sign your name in ink in Box #26 and print the date in Box #27, for example 05/30/2026. Carlos signs and dates the form the day he mails it.

Your signature certifies the claim is true, and an unsigned form is not valid. The edge case is a worker who cannot sign due to injury; a representative with written authority may sign, per the DIA’s conciliation rules. A common mistake is forgetting to date the form, which can raise questions about timing. People assume a typed name counts, but the DIA wants an actual signature in Box #26.

Box #28: Attorney Signature

This box is for your attorney’s signature, if you have one. If you are filing on your own, leave Box #28 blank. Maria, filing pro se, leaves it empty.

Only a lawyer who represents you signs here, and an attorney must also file through their online DIA account rather than by mail. The edge case is hiring a lawyer later; you can file now and add counsel afterward using the Form 114 – Notice of Appearance. A common mistake is a pro se filer signing here by accident, which can confuse who represents you. People think they need a lawyer to file at all, but you can leave this blank and file on your own.

Three Filled-Out Examples Using Real Scenarios

These three examples follow the most common situations injured workers face. Each shows what one named person enters across the key sections of Form 110.

Scenario 1: Carlos, Whose Claim Was Denied by the Insurer

Carlos Rivera, a warehouse worker, hurt his back lifting boxes and got a Form 104 – Notification of Denial from the insurer. He files Form 110 to fight the denial and get benefits.

Form Section	What Carlos Enters
Box #1 Name	Rivera, Carlos M.
Box #6 Home Address	45 Oak Street, Worcester, MA 01605
Box #10 Employer	Bay State Logistics Inc., 200 Commerce Way, Springfield, MA 01089
Box #11 Insurer	Liberty Mutual Insurance Company (copied from his Form 104)
Box #12 Date of Injury	01/15/2026
Box #13 / #14 Disability Days	01/16/2026 and 01/22/2026
Box #17a Injury/Body Part	a. 300 sprain, a. 210 back
Box #23 Benefits	Section 34 (total incapacity) and Section 30 (medical)
Box #26 / #27 Sign and Date	Signs in ink, dates 05/30/2026

Scenario 2: Maria, Whose Employer Never Filed a First Report of Injury

Maria Lopez, a hotel housekeeper, slipped on a wet floor, but her employer never filed the Form 101 – Employer’s First Report of Injury. After 30 days with no benefits, she files Form 110 herself.

Form Section	What Maria Enters
Box #1 Name	Lopez, Maria
Box #4 Date of Birth	07/22/1979
Box #6 Home Address	88 Pine Avenue, Lawrence, MA 01840
Box #11 Insurer	Carrier name she got by calling Office of Insurance
Box #12 Date of Injury	02/03/2026
Box #13 / #14 Disability Days	02/04/2026 and 02/10/2026
Box #17a Injury/Body Part	a. 100 fracture, a. 400 lower leg
Box #23 Benefits	Section 34 and Section 30
Box #26 / #28 Signatures	Signs Box #26, leaves Box #28 blank (pro se)

Scenario 3: Janet, Still Out of Work Seeking Total Incapacity Benefits

Janet Carter, a nurse with a shoulder injury, has been fully unable to work for months and wants weekly Section 34 total incapacity benefits plus payment of her medical bills.

Form Section	What Janet Enters
Box #1 Name	Carter, Janet L.
Box #5 Dependents	3
Box #6 Home Address	12 Maple Court, Quincy, MA 02169
Box #11 Insurer	Travelers Insurance Company
Box #12 Date of Injury	11/10/2025
Box #13 / #14 Disability Days	11/11/2025 and 11/17/2025
Box #17a Injury/Body Part	a. 310 strain, a. 220 shoulder
Box #23 Benefits	Section 34 (total incapacity) and Section 30 (medical)
Box #26 / #27 Sign and Date	Signs in ink, dates the day she mails it

How to File the Completed Form 110

Once your form is signed and your documents are attached, you must make three copies and route them the right way. The DIA spells out the steps in its file a claim instructions, and following them exactly keeps your claim alive. Pro se workers file by mail or in person; attorneys must file online.

By mail: Send your original signed Form 110, with copies of all supporting documents, to the Department of Industrial Accidents, Dept. 110, Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111-1750. There is no filing fee. Send a second copy to your employer’s insurance carrier by Certified Mail, with the same attachments, and keep proof of mailing. Processing leads to a conciliation notice within a few weeks.

In person: Bring your original signed form and document copies to the DIA at Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111-1750. There is no fee, and you should still mail the insurer’s copy by Certified Mail. Ask for a date-stamped copy as your proof of filing.

Online (attorneys only): If you have a lawyer, they must file Form 110 through their online DIA account, not by mail. The DIA’s fax line is (617) 727-7470 for related correspondence, though claims should be filed by the channels above. Whichever route you use, the certified-mail copy to the insurer with all attachments is required, because if those documents are not attached, the insurer’s attorney can ask the DIA to withdraw your claim for improper filing.

What Happens After You File Form 110

After the DIA receives your form, it reviews it and responds one of two ways. It either rejects the form and mails everything back with a letter naming what is missing, or it accepts the claim and schedules your conciliation. The DIA aims to schedule conciliations for about 12 working days after the claim is filed, per its conciliation guidance.

Your conciliation is held at the regional office closest to your home address on file; if your address is out of state, it goes to the Boston office. You, the insurer, and your employer all get a notice with the date and time. Your employer gets it as a courtesy and does not have to appear unless the insurer asks or had no insurance on your injury date.

At the conciliation, an informal meeting with a DIA conciliator, both sides try to reach a voluntary agreement. Bring your medical documentation, because failing to bring requested information can bar you from using it later, under 452 CMR 1.08(2). If you settle, the conciliator marks the case “adjusted”; if not, the case is referred to an Administrative Judge for a conference, the next step in the dispute resolution process.

Remember that conciliation results are not binding unless you agree to them. If the insurer filed against you to reduce or stop benefits, nothing changes at conciliation unless both sides agree. Keep your copies and your certified-mail receipt in case any question comes up about how and when you filed.

Mistakes to Avoid When Filling Out Form 110

Small errors cause most rejections, and each one costs you time while you wait for benefits. Avoid these specific mistakes.

• Naming the wrong insurance carrier. The DIA cannot schedule your conciliation, so your claim stalls until you fix it.
• Leaving Box #23 benefits unchecked. The DIA cannot tell what you want and rejects the form.
• Skipping the 1st and 5th day of disability. These top-three rejection triggers send your paperwork straight back.
• Forgetting to attach a supporting document. A claim with no medical bill, report, or witness statement is rejected on sight.
• Not mailing the insurer’s copy by Certified Mail. The insurer’s attorney can ask the DIA to withdraw your claim for improper filing.
• Listing the insurance agent instead of the carrier. Your benefits come from the carrier, so the wrong name halts processing.
• Using an outdated home address in Box #6. Your conciliation notice goes to the wrong place and you miss your date.
• Crossing the injury and body-part codes in Box #17a. Mismatched codes confuse the medical picture and slow review.
• Leaving Box #12 date of injury blank. The DIA may question whether you filed within the Chapter 152 time limits.
• Signing the attorney line (Box #28) as a pro se filer. This muddies who represents you and can cause confusion.
• Forgetting to sign Box #26 or date Box #27. An unsigned or undated form is not valid and gets returned.

Do’s and Don’ts

These quick rules keep your filing clean and on track.

• Do confirm you have the 7/2018 revision, because older versions use different box numbers.
• Do copy the carrier name exactly from your Form 104 – Notification of Denial, since accuracy here is everything.
• Do count calendar days carefully for Boxes #13 and #14, because the five-day waiting period drives your benefits.
• Do attach at least one supporting document, since a bare form is rejected automatically.
• Do mail the insurer’s copy by Certified Mail, because that receipt is your proof of proper filing.
• Do keep one full copy for yourself, in case you hire an attorney later.
• Don’t guess at the insurance carrier, because a wrong name is the top rejection cause statewide.
• Don’t leave the benefit boxes blank, since the DIA cannot process a claim with nothing checked.
• Don’t use a foreign date format, because it scrambles your injury and disability dates.
• Don’t mail only the original with no copies, since you need three total.
• Don’t skip the directions sheet, because it lists the codes you need for Boxes #10a and #17a.
• Don’t ignore the DIA hotline, because a quick call can fix a problem before it becomes a rejection.

Pros and Cons of Filing on Your Own vs. With an Attorney

Many workers wonder whether to file alone or hire help. Here is the honest tradeoff.

Pros of filing pro se:

• You pay no attorney fee up front, which helps when money is tight while you are out of work.
• You control your own timeline and file as soon as your form is ready.
• The form and directions are free and public, so you can do it with care.
• You learn your own case well, which helps you speak clearly at conciliation.
• Simple, clearly documented claims often move through conciliation without trouble.

Cons of filing pro se:

• You can miss a box, like the carrier name, and trigger a rejection that a lawyer would catch.
• You face the insurer’s attorney alone at conciliation, which can feel uneven.
• You may not know which benefit sections to check in Box #23 for your situation.
• The DIA itself recommends hiring an attorney for a conciliation, signaling the stakes.
• If the case advances to a conference or hearing, the DIA strongly advises counsel, and catching up late is harder.

FAQs

Do I need a separate form to request a conciliation?

No. Filing a complete Form 110 – Employee Claim is what triggers your conciliation. The DIA schedules it automatically once your claim is accepted, so there is no stand-alone conciliation request form.

Is there a fee to file Form 110?

No. The DIA charges injured workers no fee to file Form 110. You only need to cover your own Certified Mail cost when sending the insurer’s copy.

Do I write my injury date or my first missed workday in Box #12?

No. Box #12 is the date you were hurt or got sick, not your first missed day. Your first missed workday goes in Box #13, which is a separate entry.

Do I have to give my Social Security number in Box #2?

No. The DIA says disclosing your number is voluntary. It helps keep your file separate from others with the same name, but you can leave it blank.

Do I check more than one box in Box #23?

Yes. Check every benefit section that applies, such as Section 34 for total incapacity plus Section 30 for medical bills. Each section is a separate benefit you must claim.

Do I name the insurance agent in Box #11?

No. Box #11 needs the insurance carrier that pays benefits, not the agent or broker. The DIA cannot schedule your conciliation without the correct carrier name.

Do I sign the attorney line in Box #28 if I file alone?

No. Leave Box #28 blank if you have no attorney. You sign Box #26, and only a lawyer who represents you signs Box #28.

Do I have to mail a copy to my employer?

No. You are not required to send your employer a copy, unless you are filing for double compensation under Section 28 for willful misconduct. You must still send the insurer a copy.

Do I need to attach documents to my claim?

Yes. You must attach at least one supporting item, such as a medical bill, medical report, accident report, or witness statement. A claim with no attachments gets rejected.

Do I send the insurer’s copy by regular mail?

No. Send the insurer’s copy by Certified Mail with all the same attachments. That receipt is your proof you filed correctly, which protects your claim.

Do attorneys file Form 110 the same way I do?

No. Attorneys must file Form 110 through their online DIA account. Only unrepresented workers mail or hand-deliver a paper form.

Do I file Form 110 if my employer has no workers’ comp insurance?

No. If your employer had no insurance on your injury date, you file a claim against the Workers’ Compensation Trust Fund, which is part of the DIA.

Do I count only consecutive days for Boxes #13 and #14?

No. Count the calendar days you could not earn full wages, even if they are not back to back. The fifth such day goes in Box #14.

Do conciliation results bind me automatically?

No. Conciliation results are not binding unless you agree to them. If no agreement is reached, your case is referred to an Administrative Judge for a conference.