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Denial of Claim
If an insurer decides to contest your claim they must notify you by certified mail of the denial, telling you the reasons, and must tell you of your right to file a claim with the DIA. The same procedure is followed if they began paying, and then stop, or request the DIA's permission to stop your benefits. If your initial claim is denied by the insurer, you may appeal that denial by filing with the DIA.

Your claim must be submitted on a Form 110 Employee’s Claim Form. The form must be filled out completely and accurately. All claim forms must be submitted to the Boston Office. You must also send a copy to the insurer. By law your employer must provide you with the name and address of the insurer. If your employer refuses to provide this information, or they do not have workers’ compensation insurance, notify the DIA at once.

We recommend that you keep a copy of the Form 110 for your own files. When you go to any DIA office for a proceeding, be sure to bring with you any letters the insurer or the DIA has sent you, along with any other relevant paperwork, especially the notice telling you of the proceeding.

Filing a workers' compensation claim is a complicated and difficult task. If you would like your claim to be reviewed by an attorney, complete the form below for a free evaluation.

Free Denial of Claim Consultation

Title:
First Name:	*
Middle Name:
Last Name:	*
Home Phone:	*
Cell Phone:
Work Phone:
Email Address:
Address:	*
City:	*
State, Zip:	* *
What is the best way to reach you? Please provide the best place, time and method for contacting you.

Injured Person Information:

Date of Birth / Age: (ex. mm/dd/yyyy or 54)
Were you injured?	Yes No
If not, who are you inquiring on behalf of?

If you are NOT inquiring on your own behalf,
what is your relationship to the injured person?

Is the person deceased?

Yes No

If deceased, what is the cause of death
as stated on the death certificate:

Date of Death: (ex. mm/dd/yyyy)
Was an autopsy performed?	Yes No
If not deceased, does the injury prevent you or the victim from working?	Yes No

If yes, when did you/victim stop working?
What is the approximate lost wages due to the injury?

Accident / Injury Information:

Date of Accident:	*
City where accident occured:	*
State where accident occured:	*

Please briefly explain the incident that caused the injury:
Who do you believe was at fault in causing the injury, and what do you believe they did wrong?
Describe the injuries in detail:

Do you believe the injuries are permanent?

Yes No

Case Description*
Please explain exactly what happened, trying to state
as thoroughly as possible who you believe was responsible
and why you believe that person was negligent:

Please explain the full extent of the victims injuries:

Comments / Additional Information
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understanding the facts of your case?

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