Massachusetts > Workers Comp
Agreement For Redeeming Liability By Lump Sum - For Injuries Before 11-1-86 117A - Massachusetts
| Agreement For Redeeming Liability By Lump Sum - For Injuries Before 11-1-86 Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 117A The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2107 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): AGREEMENT FOR REDEEMING LIABILITY BY LUMP SUM UNDER G.L. CH. 152, SEC. 48 FOR INJURIES OCCURRING BEFORE NOV. 1, 1986 Page 1 of 2 Please Print or Type Board Number ______________________________________ Employee _____________________________________________________ Insurer Or Self-insurer ________________________________ Employer _____________________________________________________ Insurer's Address ___________________________________________________________________________________________________ LUMP SUM AMOUNT $________________________________________________________________________________ Total Deductions $___________________________________ Total Payments Net to Claimant $_______________________________________________ $___________________________________ Insurer's Claim Number _________________________________________ Received of _________________________________________ the Lump Sum of _______________________________________________ ____________________________________ dollars and ________________ cents ($___________________) making with weekly payments already received by me , the total sum of ________________ dollars and __________________ cents ($_____________). Said payments are received in redemption of the liability for all weekly payments now or in the future due me under the Workers' Compensation Act, for all injuries received by_____________________________________________________________________________ on or about ____________________________________ while in the employ of _________________________________________________ subject to the approval of the Department of Industrial Accidents. _________________________________________ Claimant's Signature _________________________________________ Witness's Signature _________________________________________ Claimant's Address _________________________________________ Witness's Address _________________________________________ _________________________________________ Signature of Insurer's Rep. _________________________________________ _________________________________________ Date of Agreement _____________________________________________________________________________________________________________________________________________________________________________________________________________ STRIKE OUT IF NOT APPLICABLE I understand that from the LUMP SUM amount stated above, the amounts listed below will be deducted and paid to the following parties: 1. $_____________________ ________________________________________ Attorney's Fee Liens Name ________________________________________ Address 2. $_____________________ ________________________________________ 3. $_____________________ ________________________________________ 4. $_____________________ ________________________________________ 5. $_____________________ ________________________________________ 6. $_____________________ ________________________________________ 7. $_____________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ______________________________________________________________________________________ STRIKE OUT IF NOT APPLICABLE I understand that, in addition to the LUMP SUM amount stated above, the insurer or self-insurer will pay all outstanding reasonable medical bills incurred as of this date: I understand that after all of the above deductions, including attorneys fees and other liens, I will receive the net amount of $_________________. I further understand that this is a complete and final settlement of my claim and that I will not be able to reopen my claim or seek further benefits because of this injury. I am fully satisfied with this settlement. Claimant's Signature and Date (over) Witness's Signature and Date American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Employee: Age: ______ Average Weekly Wage: ________________ Dependents: ______ Comp. Rate: ________ Social Security No.*: _________________________ On Social Security Disability: Yes ___ No ___ Occupation: ________________________________ If yes, from what date?: ____________________ Injury: Nature: _____________________________________________________________________________ Place and Date of all injuries included ____________________________________________________ ___________________________________________________________________________________ Cause:______________________________________________________________________________ Liability: Accepted: Yes____ No ____ If No, state reason __________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ If accepted, what is pending issue:________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Medical: Original Diagnosis: ___________________________________________________________________ ____________________________________________________________________________________ Present Medical Condition: _____________________________________________________________ Present Work Capacity: ________________________________________________________________ ____________________________________________________________________________________ PERTINENT MEDICAL REPORTS AND BILLS SHOULD BE ATTACHED HERETO COMPENSATION PAID: §34 $_____________ §35 $_____________ §35A $_____________ §36 $_____________ §34A $_____________ §31 $_____________ PLEASE GIVE A BRIEF HISTORY OF THE CASE AND INDICATE WHY THE SETTLEMENT IS IN THE EMPLOYEE'S BEST INTEREST (Specify any requested allocation of claimant's net amount): Signatures: Counsel for Insurer Counsel for Employee American LegalNet, Inc. www.FormsWorkFlow.com *Disclosure of Social Security Number is Voluntary. It will aid in the processing of this document. Form 117A - Revise
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