Massachusetts > Workers Comp
Request For Lump Sum Conference 116 - Massachusetts
| Request For Lump Sum Conference Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 116 The Commonwealth of Massachusetts Department of Industrial Accidents Department 116 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): REQUEST FOR LUMP SUM CONFERENCE REQUESTING CONFERENCE FOR APPROVAL OF SETTLEMENT BEFORE: ADMINISTRATIVE LAW JUDGE CONCILIATOR Please Print or Type 1. Employee's Name (Last, First, MI): 5. Home Address (No., Street, City, State & Zip Code): E M P L O Y E E CODES ARE ON THE REVERSE SIDE 2. Social Security Number*: 3. Home Telephone No.: 6. Date of Birth: 4. Number of Dependents: 7. Name of Employee's Attorney (Last, First, MI) if applicable: 8. Attorney's Telephone No.: 9. Attorney's Address, Including Firm's Name (No., Street, City, State & Zip Code): 10. Employer's Name & Address (No. & Street, City, State, Zip Code): I N J U R Y I N F O R M A T I O N 11. DATE OF INJURY (mm/dd/yyyy): 12a. DIA Board # (if known) 12b. Insurer's Case/Claim #: 14. Self-Insured?: Yes No 13. Insurance Carrier's Name and Address (No. & Street, City, State, Zip Code): If Yes, Self -insurer number: 15. Name & Address of Insurance Carrier's Attorney (No. & Street, City, State, Zip Code): 16. Telephone Number of Insurer's Attorney: 17. Briefly Describe How Injury/Exposure Occurred and Body Part(s) involved: 17a. Injury Code(s) a. b. c. to body part to body part to body part Body Part Code(s) a. b. c. 18. Preparer's Signature: 19. Preparer's Name (Please Print or Type) 20. Date (mm/dd/yyyy): UNDER CERTAIN CIRCUMSTANCES, THE WRITTEN CONSENT OF THE EMPLOYER AND/OR THE WRITTEN CONSENT OF THE DIRECTOR OF THE OFFICE OF EDUCATION AND VOCATIONAL REHABILITATION MAY BE REQUIRED. SEE FORMS 116A & 116B. DO NOT FILE FORMS 116A, 116B OR 116C WITH THIS FORM. THOSE DOCUMENTS SHOULD BE FILED AT THE TIME OF THE LUMP SUM PROCEEDING. *Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents. Form 116 - Revised 7/2010 - Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com INDUSTRY CODES Agriculture, Forestry and Fishing 01 Agriculture Production - Crops 02 Agriculture Production - Livestock 07 Agricultural Services 08 Forestry 09 Fishing, Hunting and Trapping Mining 10 Metal Mining 12 Coal Mining 13 Oil and Natural Gas 14 Nonmetallic Minerals, Except Fuels Construction 15 General Building Contractors 16 Heavy Construction, Ex. Building 17 Special Trade Contractors Manufacturing 20 Food and Kindred Products 21 Tobacco Products 22 Textile Mill Products 23 Apparel and Other Textile Products 24 Lumber and Wood Products 25 Furniture and Fixtures 26 Paper and Allied Products 27 Printing and Publishing 28 29 30 31 32 33 34 35 36 37 38 39 Chemicals and Allied Products Petroleum and Coal Products Rubber and Misc. Plastic Products Leather and Leather Products Stone, Clay and Glass Products Primary Metal Industries Fabricated Metal Products Industrial Machinery and Equipment Electronic and Other Electrical Equipment Transportation Equipment Instruments and Related Products Miscellaneous Manufacturing Industries 51 Wholesale Trade - Non-durable Goods Retail Trade 52 Building Materials and Garden Supplies 53 General Merchandizing 54 Food Stores 55 Automotive Dealers and Service Stations 56 Apparel and Accessory Stores 57 Furniture and Home Furnishing Stores 58 Eating and Drinking Establishments 59 Miscellaneous Retail Finance, Insurance and Real Estate 60 Depository Institutions 61 Non-depository Institutions 62 Security and Commodity Brokers 63 Insurance Carriers 64 Insurance Agents, Brokers and Service 65 Real Estate 67 Holding and Other Investment Officers Services 70 Hotels and Other Lodging Places 72 Personal Services 73 Business Services 75 Auto Repair Services and Parking 76 Miscellaneous Repair Services 78 79 80 81 82 83 84 86 87 88 89 Motion Pictures Amusements and Recreation Services Health Services Legal Services Educational Services Social Services Museums, Botanical, Zoological Gardens Membership Organizations Engineering and Management Services Private Households Services, NEC Transportation and Public Utilities 40 Railroad Transportation 41 Local and Interurban Passenger Transit 42 Trucking and Warehousing 43 U.S. Postal Service 44 Water Transportation 45 Transportation by Air 46 Pipelines, Except Natural Gas 47 Transportation Services 48 Communications 49 Electric, Gas and Sanitary Services Wholesale Trade 50 Wholesale Trade - Durable Goods Public Administration 91 Executive, Legislative and Garden 92 Justice, Public Order, and Safety 93 Finance, Taxation, and Monetary Benefits 94 Administration of Human Services 95 Environmental Quality and Housing 96 Administration of Economic Program 97 National Security and International Affairs Non-classifiable Establishments 99 Non-classifiable Establishments NATURE OF INJURY OR ILLNESS CODES 100 110 120 130 140 160 170 190 200 210 250 300 310 400 900 950 995 999 150 151 152 153 154 156 Amputation or Erucloation Asphyxia or Strangulation Etc. Burns (Heat) Burns (Chemical) Concussion Contusion, Crushing, Bruise Cut, Laceration, Puncture Dislocation Electric Shock, Electrocution Fracture Hernia, Rupture Scratches, Abrasions Sprains, Strains Multiple Injuries No Injury Damage to Prosthetic Devices No Other Injury, NEC** Non-classifiable Infective or Parasitic Disease Infective or Parasitic Disease, UNS* Amebiasis Anthrax Brucellosis Conjunctivitis and Opthalmia Tetanus 157 Tuberculosis 159 Other Infective or Parasitic Diseases Dermatitis 180 Dermatitis, UNS* 183 Primary Infections of the Skin 184 Other Skin Conditions 185 Dermatitis, Allergenic or Contact 189 Skin Condition, NEC** Poisoning Systemic 270 Poisoning, Systemic, UNS* 271 Due to Toxic Materials other than Lead 272 Diseases of the Blood and Blood Forming Organs 273 Upper Respiratory Conditions 274 Influenza, Pneumonia, Etc. 276 Other Diseases of the Gastro-Intestinal Tract 278 Effects of Lead 279 Other Toxic Effects of One System Only Respiratory Systems, Conditions of 570 Respiratory Systems, Conditions of 571 Upper Respiratory 572 Asthma, Influenza, Pneumonia Pneumoconiosis 280 Pneumoconiosis 281 282 283 284 285 286 287 289 560 561 562 Aluminosis Anthracosis Asbestosis Byssinosis Siderosis Silicosis Other Pneumoconioses Pneumoconiosis and Tuberculosis Nervous System, Conditions of Nervous System, Conditions of - NEC** Diseases of the Central Nervous System Diseases of the Nerves and Peripheral
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