Fillable Commonwealth of Massachusetts Department of Industrial Accidents Form-112 Appeal to Reviewing Board

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Commonwealth of Massachusetts Department of Industrial Accidents Form-112 Appeal to Reviewing Board

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The Commonwealth of Massachusetts
Department of Industrial Accidents – Department 112
Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111-1750
Info. Line (800) 323-3249 Inside Mass. / (857) 321-7470 Outside Mass.
www.mass.gov/dia
APPEAL TO REVIEWING BOARD
DIA Board #
(If Known):
FORM 112
Form 112 - Revised 7/2019 - Reproduce as needed.
*Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents.
Please Print Clearly or Type. Unreadable forms will be returned.
1. Party Filing this Form is:
Insurer Employee Other (please specify) _______________________
5. Employee’s Name (Last, First, MI):
9. Employer’s Name & Address (No. and Street, City, State, Zip Code):
10. Name of Workers’ Compensation Insurance Carrier:
21. Preparer’s Signature (“On-File” is NOT acceptable. Must have signature.):
6. Employee’s Social Security Number*:
7. Employee’s Address (No. and Street, City, State, Zip Code):
22. Date Prepared (mm/dd/yyyy):
THIS FORM IS TO BE FILED WHEN EITHER PARTY SEEKS TO APPEAL THE
HEARING DECISION OF AN ADMINISTRATIVE JUDGE ON LEGAL GROUNDS.
8. Employee’s Telephone Number:
11. Name of Insurer’s Attorney:
19. Preparer’s Name & Address (Please Print or Type):
Please Print or Type INSTRUCTIONS ON REVERSE SIDE
2. Date of Decision (mm/dd/yyyy): 3. Name of Judge Who Issued Hearing Decision: 4. Date of Injury (mm/dd/yyyy):
12. Attorney’s Telephone Number:
14. Name of Employee’s Attorney:
15. Attorney’s Telephone Number:
16. Address of Employee’s Attorney (No. and Street, City, State, Zip Code):
13. Address of Insurer’s Attorney (No. and Street, City, State, Zip Code):
17. Briefly set out the basis for the appeal under M.G.L. c. 152, §11C:
18. Check Where Applicable:
A. Filing Fee Attached.
B. Request for Waiver of Filing Fee based upon indigence. Affidavit in Support of Waiver of Filing Fee must be submitted before your
appeal will be docketed.
C. Request Verbatim Transcript.
D. Verbatim Transcript Waived.
20. Preparer’s Telephone Number
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APPEAL TO REVIEWING BOARD
FILING INSTRUCTIONS
1. WHEN TO FILE: File Form 112 the Department of Industrial Accidents within thirty (30) days from
the date of a hearing decision by an Administrative Judge along with the requisite filing fee. This form
is not to be used to appeal a conference order issued by an Administrative Judge. Please Use Form 121
for that purpose.
2. WHERE TO FILE:
3. FILING FEES:There is no filing fee for injuries occurring prior to November 1, 1986. For injuries
after November 1, 1986, this form must be accompanied by a fee of thirty (30) percent of the average
weekly wage in the Commonwealth at the time of the appeal, unless the fee is waived by the Reviewing
Board due to indigence. Please make checks payable to “Massachusetts Industrial Accidents Special
Fund” and forward to the above address. If you are unable to pay the filing fee and wish to have it
waived, you must submit an Affidavit in Support of Waiver of Filing Fee. This affidavit must be
submitted before the case can be docketed.
4. A copy of the Administrative Judge’s decision must be attached to this appeal.
Reviewing Board Appeals
Department of Industrial Accidents
The Lafayette City Center
2 Avenue de Lafayette
Boston, MA 02111-1750
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Commonwealth of Massachusetts Department of Industrial Accidents Form-112 Appeal to Reviewing Board

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Completed 22 May 2020

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