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Get Employee's Claim - Mass . Gov - Mass

800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 http://www.mass.gov/dia Print Form EMPLOYEE S CLAIM FOR USE BY EMPLOYEES OR DEPENDENTS CLAIMING BENEFITS AS A RESULT OF INJURY OR DEATH. ALL OTHER CLAIMANTS SHOULD USE FORM 115 IMPORTANT - INSTRUCTIONS AND CODES ON THE REVERSE SIDE - Please Print Legibly or Type - Unreadable forms will be returned. 2. Social Security Number*: 3. Home Telephone No.: 4. Date of Birth: 1. Employee s Name (Last, First, MI): E M P L O Y E E.

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