Affidavit Of Employee In Application For Trust Fund Benefits {170}

AFFIDAVIT OF EMPLOYEE IN APPLICATION FOR TRUST FUND BENEFITS I, , do swear and depose as follows: (Name of employee/claimant) 1. I reside at . Home telephone # . 2. On the date of my injury my employer was . The address of my employer is . My supervisor's name is . 3. While working for my employer, I was injured on . (Date of Injury) The injury occurred at . (Address, city and town) Witnesses to my injury were (Name and address of witness) (Name and address of witness) 4. I have been informed that my employer, at the time of my injury, did not carry workers' compensation insurance as required by Massachusetts law (M.G.L. c. 152, 247 25A). 5. I am now applying to the Workers' Compensation Trust Fund (WCTF) for appropriate benefits. 6. At the time of my injury, I was earning wages of $ per week from my employer by CASH - CHECK. (Circle one) SIGNED UNDER THE PAINS AND PENALTIES OF PERJURY THIS DAY OF 20 (Date) (Month) (Year) Signature of Employee/Claimant The Commonwealth of Massachusetts Department of Industrial Accidents Department 170 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 DIA USE ONLY FORM 170 Form 170 7/2019 American LegalNet, Inc. www.FormsWorkFlow.com