Massachusetts > Workers Comp

Conference Memorandum Cover Sheet 140 - Massachusetts

Conference Memorandum Cover Sheet Form. This is a Massachusetts form and can be used in Workers Comp .
 Fillable pdf Last Modified 6/18/2014
Get this form for FREE as a print-only pdf

FORM 140 The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 Info. Line 800-323-3249 ext. 7470 in Mass. Outside Mass. - 617-727-4900 ext. 7470 http://www.mass.gov/dia DIA Board # (If Known): CONFERENCE MEMORANDUM Page 1 of 2 Please Print or Type THIS CONFERENCE MEMORANDUM COVER SHEET , SIGNED BY COUNSEL SHALL BE FILED WITH THE ADMINISTRATIVE JUDGE AT THE START OF THE CONFERENCE. 1. Date (mm/dd/yyyy): C A S E I N F O R M A T I O N 3. Claimant's Name & Address (No., Street, City, State & Zip Code): 2. List Multiple DIA Board Numbers If Necessary: 4. Name, Address & Email Address of Claimant's Attorney: 5. Insurance Carrier's Name & Address: 6. Name, Address & Email Address of Insurer's Attorney: 7. Employer's Name, Address & Email Address: 8. Name, Address & Email Address of Employer's Attorney: 9. Date of Injury (mm/dd/yyyy): E M P L O Y E E & I N J U R Y 10. Nature & Cause of Injury: 11. Average Weekly Wage: 12. No. of Dependents: 13. Has Any Compensation Been Paid: Yes 14. If Yes for #13 Please State Period and Type: From _____/_____ /_______ From _____/_____/_______ To ______/______/______ Under __________ at $ _______________; and No Accepted Liability Pay Without Prejudice To _____/______/______ Under § __________ at $ _______________ 15. Claims for Compensation: Total Incapacity Under § _______From ____/____ /_____ AND/OR To ______/______/______ at $ ___________ per week; To ______/______/______ at $ ___________ per week Partial Incapacity Under § _______From ____/____ /_____ 36 Benefits ________________________ OTHER (specify) __________________________________________ I S S U E S I N D I S P U T E 16. Issues in Dispute (Check all that apply): Liability Fraud OTHER Average Weekly Wage Disability Extent Causal Relationship to Work §14 (2) (explain ) _________________________________ §14 (1) (specify)________________________________________________________________ _______________________________________________________________________ Attorney Fee Issues _____________________________________________________________ Form 140 - Revised 7/2013 Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com (OVER) Page 2 of 2 Documents to be sent to Impartial Physician are submitted in hard copy, tabbed and indexed. I certify that a copy of these documents have been submitted in electronic format or CD form (PDF, bookmarked, and text recognized). If not, I certify that a copy of these documents along with an Index page, will submitted in electronic format or CD form (PDF, bookmarked, and text recognized) within 14 days of the date of the Conference Order. Note: If hypothetical questions are submitted, they must be as a separate document. Insurer's Attorney Initials _____________ Employee's Attorney Initials ______________ Non-medical documents are submitted in hard copy, tabbed and indexed. I certify that a copy of these documents have been submitted in electronic format or CD form (PDF, bookmarked and text recognized). Insurer's Attorney Initials ______________ Employee's Attorney Initials _______________ PURSUANT TO 452 C.M.R. 1.10(2), COMPLETE THE FOLLOWING: Medical Issue(s) in Dispute: ____________________________________________________________ Medical Specialty of the Impartial Physician: _________________________________________________ If there is agreement, name of the Impartial Physician: _______________________________________ Injured Body Part(s): __________________________________________________________________ If an Impartial is not needed, a separate Form 121A must be filed at Conference. I certify the above to be complete and accurate: Employee's Attorney Signature: ____________________________________________________________ Print Name: ____________________________________________________________________________ Insurer's Attorney Signature: ______________________________________________________________ Print Name: ____________________________________________________________________________ For Department Use Only Disposition Order: ______________________________________________ From: _________________________________ To ________________________________ From: ________________________________ To ________________________________ Attorney's Fee: _______________________________________________ Notes: _________________________________________________________________________________________ _________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com
Link/Embed this Document
URL
Embed


Popular Searches

  1. Request for entry of default
  2. stipulation of discontinuance
  3. Preliminary Change of Ownership Report
  4. Notice and Acknowledgment of Receipt
  5. Decree of Dissolution of Marriage
  6. proof of service of summons
  7. Petition to Expunge
  8. writ of replevin
  9. fee waiver
  10. Income and Expense Declaration

Bookmark and Share