Massachusetts > Workers Comp
Notification Of Arbitration Award 124A - Massachusetts
| Notification Of Arbitration Award Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 124A The Commonwealth of Massachusetts Department of Industrial Accidents Department 124A 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): NOTIFICATION OF ARBITRATION AWARD ATTACH COPIES OF ARBITRATION AWARD TO THIS FORM. SEND COPIES TO ALL PARTIES 1. Employee's Name (Last, First, MI): 2. Employee's Social Security Number*: 3. Employee's Telephone Number: 4. Employee's Address (No. and Street, City, State, Zip Code): 5. Name of Employee's Attorney: 6. Telephone Number of Employee's Attorney: 7. Attorney's Address: 8. Employer's Name & Address (No. and Street, City, State, Zip Code): 9. Insurer's Name & Address (No. and Street, City, State, Zip Code): 10. Name of Insurer's Attorney: 11. Telephone Number of Insurer's Attorney: 12. Attorney's Address: 13. Arbitrator's Name: 14. Arbitrator's Firm Name: 15. Arbitrator's Business Address (No., Street, City, State, Zip Code): 16. Arbitrator's Signature: 17. 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 124A - Revised 7/2010 - Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com
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