For injuries occurring on or after November 1, 1986, this form must be accompanied with a fee of thirty (30) percent of state average weekly wage at the time of the appeal, unless the filing fee has been waived by the Reviewing Board due to indigency of the employee. (As of October 1, 2007, the fee is $ 313.06) Make check out to "Massachusetts Industrial Accidents Special Fund". There is no filing fee for injuries occurring prior to November 1, 1986.

Mail appeal, and fee to:

DIA
Reviewing Board Fee Processing
P.O. Box 9106
Essex Station
Boston, MA 02111-9106