Massachusetts > Workers Comp
Consent To The Payment Of Lump Sum Settlement 116A - Massachusetts
| Consent To The Payment Of Lump Sum Settlement Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 116A The Commonwealth of Massachusetts Department of Industrial Accidents Department 116A 600 Washington Street 7th Floor, Boston, Massachusetts 02111 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): CONSENT OF EMPLOYER TO LUMP SUM SETTLEMENT I,____________________________, sole proprietor/partner/corporate officer of ____________________________________________________________ (business name) located at ______________________________________________________ (address) _______________________________,_______________________________ (city) (state) (workers' comp. insurance carrier) and experience-modified insured of__________________________________ hereby consent to payment of a lump sum settlement in the gross amount of $__________________________________ in workers' compensation in the case of _____________________________ . The terms of such settlement are more fully set forth in the attached lump sum agreement. Signed this ____________________ day of _____________________, 20__ , pursuant to the provisions of Section 48 of Chapter 152 of the General Laws of Massachusetts as most recently amended by Section 74 of Chapter 398 of the Acts of 1991. _______________________________ (signature) Reproduce as needed. Form 116A Revised 8/2001 American LegalNet, Inc. www.USCourtForms.com
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