Fillable Commonwealth of Massachusetts KOR DIA File Request

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Commonwealth of Massachusetts KOR DIA File Request

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The Commonwealth of Massachusetts KOR DIA File Request form is 2 pages long and contains:

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DIA FILE
REQUEST
Please fill out this information as fully as possible.
TO: The Keeper of Records
Dept. of Industrial Accidents
Lafayette City Center
2 Avenue de Lafayette
Boston, MA 02111-1750
Requesting Party:
Injured Worker/Employee
Employee’s Counsel:
Current or
Former
Insurer’s Counsel
3
rd
Party Representative:
(Name of 3
rd
Party)
Other:
(Please Specify)
PLEASE NOTE: If you are not listed in our records as a party to the case you wish to view
and/or obtain copies of documents from, we will need a signed authorization from the
Employee.
Name of Requester:
Address of Requester:
Telephone Number:
Date Requested
Employee Name:
Address:
Soc. Sec. # (if known):
Date(s) of Injury:
DIA #(s) (if known):
Employer(s):
Workers’ Comp. Insurer:
DIA FILE REQUEST – p.
2
Please add any additional information you may have that will help us in locating the file.
I Am Requesting:
Access to view the workers’ compensation record(s)
(Please be advised that after viewing a file, it may not be possible to obtain
file copies the same day)
A copy of the entire file(s)
A copy of the Lump Sum Settlement
A copy of a specific form/document, i.e., Employer’s First Report of Injury ,
Employee’s Claim, Agreement to Pay Compensation, Conference Order, Hearing
Decision, etc.
(Specify Form/Document)
(7/2019)
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Commonwealth of Massachusetts KOR DIA File Request

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Completed 17 May 2020

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