Form 112 "Appeal to Reviewing Board" - Massachusetts

What Is Form 112?

This is a legal form that was released by the Massachusetts Department of Industrial Accidents - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2019;
  • The latest edition provided by the Massachusetts Department of Industrial Accidents;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 112 by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Industrial Accidents.

ADVERTISEMENT
ADVERTISEMENT

Download Form 112 "Appeal to Reviewing Board" - Massachusetts

Download PDF

Fill PDF online

Rate (4.4 / 5) 71 votes
Page background image
The Commonwealth of Massachusetts
FORM 112
DIA Board #
Department of Industrial Accidents – Department 112
(If Known):
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
THIS FORM IS TO BE FILED WHEN EITHER PARTY SEEKS TO APPEAL THE
HEARING DECISION OF AN ADMINISTRATIVE JUDGE ON LEGAL GROUNDS.
Please Print or Type
INSTRUCTIONS ON REVERSE SIDE
1. Party Filing this Form is:
Insurer
Employee
Other (please specify) _______________________
2. Date of Decision (mm/dd/yyyy
:
3. Name of Judge Who Issued Hearing Decision:
4. Date of Injury (mm/dd/yyyy):
)
5. Employee’s Name (Last, First, MI
6. Employee’s Social Security Number*:
:
)
7. Employee’s Address (No. and Street, City, State, Zip Code):
8. Employee’s Telephone Number:
C
A
S
9. Employer’s Name & Address (No. and Street, City, State, Zip Code):
E
I
N
10. Name of Workers’ Compensation Insurance Carrier:
F
O
R
11. Name of Insurer’s Attorney:
M
12. Attorney’s Telephone Number:
A
T
I
13. Address of Insurer’s Attorney (No. and Street, City, State, Zip Code):
O
N
14. Name of Employee’s Attorney:
15. Attorney’s Telephone Number:
16. Address of Employee’s Attorney (No. and Street, City, State, Zip Code):
G
§
17. Briefly set out the basis for the appeal under M.G.L. c. 152,
11C:
R
O
U
N
D
S
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.
19. Preparer’s Name & Address (Please Print or Type):
20. Preparer’s Telephone Number
21. Preparer’s Signature (“On-File” is NOT acceptable. Must have signature.):
22. Date Prepared (mm/dd/yyyy):
-
*Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents.
Form 112
Revised 7/2019 - Reproduce as needed.
Please Print Clearly or Type. Unreadable forms will be returned.
The Commonwealth of Massachusetts
FORM 112
DIA Board #
Department of Industrial Accidents – Department 112
(If Known):
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
THIS FORM IS TO BE FILED WHEN EITHER PARTY SEEKS TO APPEAL THE
HEARING DECISION OF AN ADMINISTRATIVE JUDGE ON LEGAL GROUNDS.
Please Print or Type
INSTRUCTIONS ON REVERSE SIDE
1. Party Filing this Form is:
Insurer
Employee
Other (please specify) _______________________
2. Date of Decision (mm/dd/yyyy
:
3. Name of Judge Who Issued Hearing Decision:
4. Date of Injury (mm/dd/yyyy):
)
5. Employee’s Name (Last, First, MI
6. Employee’s Social Security Number*:
:
)
7. Employee’s Address (No. and Street, City, State, Zip Code):
8. Employee’s Telephone Number:
C
A
S
9. Employer’s Name & Address (No. and Street, City, State, Zip Code):
E
I
N
10. Name of Workers’ Compensation Insurance Carrier:
F
O
R
11. Name of Insurer’s Attorney:
M
12. Attorney’s Telephone Number:
A
T
I
13. Address of Insurer’s Attorney (No. and Street, City, State, Zip Code):
O
N
14. Name of Employee’s Attorney:
15. Attorney’s Telephone Number:
16. Address of Employee’s Attorney (No. and Street, City, State, Zip Code):
G
§
17. Briefly set out the basis for the appeal under M.G.L. c. 152,
11C:
R
O
U
N
D
S
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.
19. Preparer’s Name & Address (Please Print or Type):
20. Preparer’s Telephone Number
21. Preparer’s Signature (“On-File” is NOT acceptable. Must have signature.):
22. Date Prepared (mm/dd/yyyy):
-
*Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents.
Form 112
Revised 7/2019 - Reproduce as needed.
Please Print Clearly or Type. Unreadable forms will be returned.
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:
Reviewing Board Appeals
Department of Industrial Accidents
The Lafayette City Center
2 Avenue de Lafayette
Boston, MA 02111-1750
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.
Page of 2