Massachusetts > Workers Comp
Appeal Of Conference Proceeding 121 - Massachusetts
| Appeal Of Conference Proceeding Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 121 The Commonwealth of Massachusetts Department of Industrial Accidents Department 121 1 Congress Street, Suite 100, Boston Massachusetts 02114-2017 Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 http://www.mass.gov/dia DIA Board # (If Known): APPEAL OF CONFERENCE PROCEEDING A COPY OF THE ADMINISTRATIVE JUDGE'S ORDER SHOULD BE ATTACHED TO THIS APPEAL. Please Print or Type 1. Case Appealed By: INSTRUCTIONS ON THE REVERSE SIDE Employee Insurer Other(Specify) 2. Medical Issue (Check one only): Appeal fee attached Appeal fee to be submitted to Department 121 Form 136, Waiver Request due to Indigence filed with Commissioner 4. Date of Order (mm/dd/yyyy): 5. Name of Judge Who Issued Order: 3. Non-Medical Issue: 6. Date of Injury (mm/dd/yyyy): 7. Employee's Name & Address (No. and Street, City, State, Zip Code): 7A. Social Security Number*: 8. Employer's Name & Address (No. and Street, City, State, Zip Code): 9. Insurance Carrier's Name & Address (No. and Street, City, State, Zip Code): 10. Name, Address & Telephone # of Insurer's Attorney: 11. Name, Address & Telephone # of Employee's Attorney: 12. Preparer's Name, Address (No. and Street, City, State, Zip Code) and Telephone #: 13. Preparer's Signature ("On-File" is NOT acceptable. Must have signature.): 14. Date Prepared (mm/dd/yyyy): *Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents. Please Print Clearly or Type. Unreadable forms will be returned. Form 121 - Revised 7/2010 - Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com APPEAL OF A CONFERENCE ORDER FILING INSTRUCTIONS 1. PURPOSE: To file an appeal of a Conference proceeding pursuant to Massachusetts General Laws c. 152, Section 10A 2. WHEN TO FILE: An appeal must be filed within 14 days from the filing date of an administrative judge's conference order. This form is NOT to be used to appeal a hearing decision of an administrative judge. WHERE TO FILE: Department of Industrial Accidents 1 Congress Street, Suite 100 Department 121 Boston, MA 02114-2017 Copies of this form must be mailed to all interested parties. 3. 4. IMPARTIAL MEDICAL EXAMINATION FEES: Submit fee within 10 days of the appeal pursuant to M.G.L. c 152, Sec. 11A (2) to Department 121 or submit Form 136 Waiver Request based on Indigence to the Commissioner's Office. Separate appeal form should be submitted for each board number. A copy of the administrative judge's conference order should be attached to this appeal. NOTICE: Failure to file a timely appeal shall be deemed to be acceptance of the administrative judge's order and findings (M.G.L. c. 152, Section 10A). 5. 6. 7. American LegalNet, Inc. www.FormsWorkFlow.com
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