Massachusetts > Workers Comp
Request For Section 37 Or 37A Proceeding 122 - Massachusetts
| Request For Section 37 Or 37A Proceeding Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 122 The Commonwealth of Massachusetts Department of Industrial Accidents Department 122 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 USE ONLY REQUEST FOR SECTION 37 OR 37A PROCEEDING Check Box: §37 Claim §37A Claim Please Print or Type E M P L O Y E E I N S U R E R 1. Employee's Name (Last, First, MI): 4. Home Address (No. & Street, City, State, Zip Code): 2. DIA Board No. for Subsequent Injury: 3. Date of Subsequent Injury: 5. Employer's Name & Address: 6. Name of Insurer: 8. Address of Branch Responsible for Case: 9. Attorney for Insurer (Name & Address): 10. Attorney's BBO#: 7. Insurer's Federal I.D. Number: Check boxes below to identify all sections of M.G.L. c. 152 relevant to the reimbursement you seek. Reimbursement for Payments for Subsequent Injury occurring before December 23, 1991: _____ §30 and ___ §30A Medical Services and Reports; _____ §31 and ___ §32 Surviving Dependents Coverage; _____ §33 Burial Expenses;_____ §34 Total Incapacity and ___ §34A Permanent and Total Incapacity; _____ §35 Partial Incapacity and ___ §35A Dependent Compensation _____ §36 Specific Permanent Injuries and _____ §36A Death. Reimbursement for Payments for Subsequent Injury occurring on or after December 23, 1991: _____ §31 and ___ §32 Surviving Dependents Coverage; ___ §33 Burial Expenses; _____ §34A Permanent and Total Disability; _____ §36A Death; _____ §30 Medical: only for benefits due under above sections. Reimbursable Payments made after 104th Week from the date of onset of Disability or Death. (Please indicate Section, Dates, Weeks, Amounts and Total Payments): 1. § ____ _______ to ______ = ____ weeks $ ______ 4. § ____ _______ to ______ = ____ weeks $ _____ 2. § ____ _______ to ______ = ____ weeks $ ______ 5. § ____ _______ to ______ = ____ weeks $ _____ 3. § ____ _______ to ______ = ____ weeks $ ______ 6. § ____ _______ to ______ = ____ weeks $ _____ Lump Sum (with attorney fees + expenses deducted) Date: _______ Amount: $ ______________ Amount: $ ______________ Medical Bills for Reimbursable Services after 104 th Week Total Payments: $ ______________ Benefit Status 11. 104th Week From Disability (mm/dd/yyyy): 13. Is pre-existing physical impairment due to: 12. Is Employee still receiving compensation?: __ Yes __ No Previous Accident 14. Preparer's Name & Title (First, MI, Last): 16. Preparer's Signature: 17. Date Prepared (mm/dd/yyyy): Previous Disease Petition Congenital Condition 15. Certificate of Service Attached: __ Yes __ No Reproduce as needed. See Reverse for Filing Requirements. Form 122 - Revised 7/2010 American LegalNet, Inc. www.FormsWorkFlow.com REQUIREMENTS TO FILE CLAIMS UNDER §§37/37A 1. After you file this claim it will be scheduled for conciliation in the Boston Office unless the parties agree in writing, at the time of the filing, that it is to be adjudicated at a specified regional office. 2. A claim requesting reimbursement under M.G.L. c. 152, §§ 37 and 37A shall be made on Form 122 and it shall be accompanied by both a certificate stating that it was served on the Office of Legal Counsel, and by a petition which sets forth and documents items which include, but are not limited to, the following: a) Employee's job description and duties; educational, military, and employment history; and, vocational training prior to the "subsequent impairment" (i.e. compensable personal injury for which petitioner seeks M.G.L. c. 152, §§37/37A reimbursement; also known as "second injury.") b) Evidence of employer's knowledge of employee's pre-existing physical impairment due to a previous accident, disease or congenital condition as evidenced by such documents as a job application, a preemployment physical report, or by employer's affidavit attesting that employer knew of the impairment not later than 30 days after the date of employment, or (for injuries occurring prior to12/23/91) by medical records which existed prior to the date of the subsequent impairment. c) Evidence that a known pre-existing physical impairment was, or was likely to be, a hindrance or obstacle to employment (i.e. medical records evidencing permanent physical restrictions, documented job modifications or accommodations which employer made on behalf of employee). d) All medical records pertaining to the subsequent impairment including attending physician reports, insurance medical examinations, and DIA impartial physician report. e) From the compensation claim involving the second injury, copies of all DIA documents which substantiate the reimbursement which the petitioner seeks, such as: (1) Employee Claim Form (110) (2) First Report of Injury (3) Agreement(s) to Compensation (4) Conference Orders, Hearing Decisions and Lump Sum Agreement f) Indemnity record for all reimbursable compensation paid after the 104th week from the date of the onset of disability or death that clearly identify the claimant, the section under which compensation was paid, the dates for which payment was made, and the amount of weekly compensation. g) Medical bills paid for all related reimbursable medical treatment received by employee after the 104th week from the date of the onset of disability. (Computer printouts which clearly identify the claimant, the service providers, and the dates of service constitute satisfactory documentation). h) A description of the subsequent impairment which includes an authoritative medical statement as to how the subsequent impairment is substantially greater (by the combined effects of such impairment and subsequent personal injury) than the disability that would have resulted from the subsequent personal injury alone, or that the subsequent injury was caused by the pre-existing impairment, and, if death results from the subsequent injury, that the death would not have occurred except for such preexisting physical impairment. Any matter not resolved at conciliation shall be scheduled for conference before an administrative judge unless parties agree to an alternative method of resolution as provided in M.G.L. c. 152, §10 B. 3. American LegalNet, Inc. www.FormsWorkFlow.com
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