10/12/2023 0 Comments Average salary dia and coForms not submitted via email will not be reviewed or considered approved. ![]() Please include the DIA Board Number in the upper right corner of the Form. This form is filed when there are 5 or more full or partial calendar days of disability, and they do not need to be consecutive.įorm 103 - Insurer's Notification of Payment - can only be filed via our online CMS system with your online account.įorm 104 - Insurer's Notification of Denial - can only be filed via our online CMS system with your online account.įorm 105 - Agreement to Extend 180 Day Payment-Without-Prejudice - Effective, Forms 105 will only be accepted via email. ![]() If there is no judge assigned, email it to AND - Updated įorm 46A - Request for § 46A Conference in Conjunction with Lump Sum Under § 48 - Email to AND 101 - Employer's First Report of Injury/Illness can only be filed via a DIA online account. If there is no judge assigned, email it to AND 19A - Section 19A Medical Mediation Agreement - If there is a judge assigned to the case, please email it to the judge and their assistant. Massachusetts Workers' Compensation COLA Offset Worksheetįorm 19 - Section 19 Agreement - If there is a judge assigned to the case, please email it to the judge and their assistant. CR-28 Massachusetts Workers' Compensation COLA Data Form
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