Massachusetts > Workers Comp
Agreement For Redeeming Liability By Lump Sum - For Injuries On Or After 11-1-86 117 - Massachusetts
| Agreement For Redeeming Liability By Lump Sum - For Injuries On Or After 11-1-86 Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 117 The Commonwealth of Massachusetts Department of Industrial Accidents 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): AGREEMENT FOR REDEEMING LIABILITY BY LUMP SUM UNDER G.L. CH. 152 FOR INJURIES OCCURRING ON OR AFTER NOV. 1, 1986 Page 1 of 2 Please Print or Type EMPLOYEE _______________________________ LUMP SUM AMOUNT $______________________ EMPLOYER _______________________________ TOTAL DEDUCTIONS $______________________ INSURER _________________________________ NET TO CLAIMANT $______________________ BOARD NUMBER _________________________ TOTAL PAYMENTS DATE OF INJURY__________________________ CHECK WHERE APPLICABLE () Liability has been established by acceptance or by standing decision of the Board, the Reviewing Board, or a court of the Commonwealth and this settlement shall not redeem liability for the payment of medical benefits and vocational rehabilitation benefits with respect to such injury. $______________________ (Weekly benefits plus lump sum) ( ) Liability has NOT been established by standing decision of the Board, the Reviewing Board, or a court of the Commonwealth and this settlement shall redeem liability for the payment of medical benefits and vocational rehabilitation benefits with respect to such injury. () () In addition to the lump-sum, the insurer agrees to pay all outstanding reasonable and related medical bills incurred as of this date. The employee is currently receiving a cost-of-living adjustment. DEDUCTIONS: From the lump-sum amount as stated above, the amount(s) listed below will be deducted and paid directly to the following parties: NAME ADDRESS 1. $_____________________ ________________________________________ Attorney's Fee ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ Form 117 Revised 7/2010 - Reproduce as needed. 2. $_____________________ ________________________________________ Attorney's Expenses Liens (Please attach documentation) (Please attach discharges) 3. $_____________________ ________________________________________ 4. $_____________________ ________________________________________ Inchoate Rights (Please specify release) 5. $_____________________ ________________________________________ 6. $_____________________ ________________________________________ 7. $_____________________ ________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com (OVER) AGREEMENT FOR REDEEMING LIABILITY BY LUMP SUM SETTLEMENT EMPLOYEE MEDICAL INFORMATION: (Page 2 of 2) Age ______ No. of Dependents _____ Average Weekly Wage $______________ Compensation Rate $_________________ Social Security No.*: ______-____-_____ Occupation _______________________ Educational Background _______________ On Social Security: YES ( ) NO ( ) YES ( ) NO ( ) On Public Employee Disability Retirement: DIAGNOSIS ___________________________________ PRESENT MEDICAL CONDITION _________________________ ______________________________________________ Present Work Capacity: ______________________________ ________________________ Third Party Action _____________________________ PLEASE GIVE A BRIEF HISTORY OF THE CASE AND INDICATE WHY THE SETTLEMENT IS IN THE EMPLOYEE'S BEST INTEREST (Specify all allocations): (Please attach a separate sheet if necessary.) Received of ____________________________________________________________ the Lump Sum of _____________________________ ____________________________________ dollars and ________________ cents ($___________________) This payment is received in redemption of the liability of 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 _________________________________________________ ____________________________________________. I fully understand that after all of the deductions herein I will receive $______________________________. I am fully satisfied with and request approval of this settlement. This agreement has been translated for me into my native language of _____________________________________. SIGNATURE CLAIMANT: CLAIMANT'S COUNSEL: INSURER'S COUNSEL: ADDRESS ZIP CODE Signed this _____________________ day of __________________________________ 20____ *Disclosure of Social Security Number is Voluntary. It will aid in the processing of this document. American LegalNet, Inc. www.FormsWorkFlow.com
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