Massachusetts > Workers Comp
Notice Of Change Appearance Of Counsel 114 - Massachusetts
| Notice Of Change Appearance Of Counsel Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 114 The Commonwealth of Massachusetts Department of Industrial Accidents Department 114 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): NOTICE OF CHANGE / APPEARANCE OF COUNSEL THIS FORM MUST BE FILED WHEN AN ATTORNEY APPEARS AS LEGAL COUNSEL FOR THE FIRST TIME OR A CHANGE OF COUNSEL HAS OCCURRED. ALL PARTIES MUST BE NOTIFIED. PLEASE NOTE - WHEN AN ATTORNEY LEAVES A FIRM AND ANOTHER ATTORNEY IN THAT FIRM TAKES OVER ACTIVE CASES, AN APPEARANCE OF COUNSEL MUST BE FILED FOR EACH MATTER. 2. Employee's Social Security Number*: Please Print or Type 1. Employee's Name (Last, First, MI): E M P L O Y E E & I N S. 3. Employee's Address (No. and Street, City, State, Zip Code): Check box if this is a new address 5. Employer's Name & Address (No. and Street, City, State, Zip Code): 4. Date of Injury (mm/dd/yyyy): Check box if this is a new address 6. Insurance Carrier's Name: 8. Insurance Carrier's Address (No. and Street, City, State, Zip Code): 7. Self-Insured?: Yes If Yes - Self Insurer #: No 9. PLEASE ENTER MY APPEARANCE FOR: Employee Insurer Third Party Other (Specify) ______________________________ 10. EMPLOYEE HAS DISCHARGED ME AS COUNSEL 11. COUNSEL HAS BEEN REPLACED BY SUCCESSOR COUNSEL AND IS WITHDRAWING FROM REPRESENTATION OF: Employee Insurer Third Party Other (Specify) ________________ Attach Appearance of Successor Counsel 12. COUNSEL FOR: Employee Insurer Third Party Other (Specify) ________________________ REQUESTS PERMISSION TO WITHDRAW PURSUANT TO 452 C.M.R. 1.18 (3) 13. APPROVED BY: ___________________________________ (Name) ________________________ (Title) _____________________________ (Date - mm/dd/yyyy) __________________________________________________________________ (Signature) ON BEHALF OF THE DIVISION OF DISPUTE RESOLUTION 14. Attorney's Name & Address: Check box if this is a new address 15. Attorney's Board of Bar Overseer's Number: 16. Attorney's Telephone Number: 17. Attorney's Signature: 18. 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 114 - Revised 7/2010 - Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com
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