Massachusetts > Workers Comp
Last Best Offer At Conference 141 - Massachusetts
| Last Best Offer At Conference Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 141 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): LAST BEST OFFER AT CONFERENCE Please Print or Type This form is for use at conference pursuant to M.G.L. Chapter 152, sec. 10A(2) in cases involving claims for further weekly compensation or complaints for discontinuance or modification of such compensation when the insurer's liability for the employee's industrial injury has already been established. EMPLOYEE: EMPLOYER: INSURER: DIA BOARD #: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ $________________________________ Employee's offer for weekly compensation Brief Description of basis for offer: Submitted by: ______________________________ Date (mm/dd/yyyy): Insurer's offer for weekly compensation Brief Description of basis for offer: $________________________________ Submitted by: ______________________________ Date (mm/dd/yyyy): JUDGE'S FINDING IF DIFFERENT FROM ABOVE: COMPENSATION: $ BASIS FOR JUDGE'S FINDING: ___________________________________ ADMINISTRATIVE JUDGE DATE Form 141 - Revised 7/2010 - Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com
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