Massachusetts > Workers Comp
Temporary Conference Memorandum Cover Sheet 140 - Massachusetts
| Temporary Conference Memorandum Cover Sheet Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 140 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): TEMPORARY CONFERENCE MEMORANDUM COVER FORM 1. Date (mm/dd/yyyy): C A S E I N F O R M A T I O N 2. Conference Location: 3. DIA Board Number: Page 1 of 2 Please Print or Type THIS CONFERENCE MEMORANDUM COVER SHEET , SIGNED BY COUNSEL SHALL BE FILED WITH THE ADMINISTRATIVE JUDGE AT THE START OF THE CONFERENCE. 4. Claimant's Name & Address (No., Street, City, State & Zip Code): 5. Claimant's Tel. Number: 6. Name and Address of Claimant's Attorney: 7. Claimant's Attorney's Tel. Number: 8. Insurance Carrier's Name & Address: 9. Name & Address of Insurer's Attorney: Tel. Number: 10. Employer's Name & Address: 11. Name & Address of Employer's Attorney: E M P L O Y E E & I N J U R Y I S S U E S I N D I S P U T E 12. Date of Injury (mm/dd/yyyy): 13. Nature & Cause of Injury: Tel. Number: 14. Average Weekly Wage: 15. No. of Dependents: 16. Has Any Compensation Been Paid: Yes Accepted Liability No Pay Without Prejudice 17. If Yes for #16 Please State Period and Type: From ____________ To _______________ and From _______________ to _______________ At a Rate of $____________________ per Week Under §34 At a Rate of $____________________ per Week Under §35 - Plus Dependency at $__________ /week 18. Claims for Compensation: Temporary Total Incapacity - From _________________ To ______________ at $ _____________________ per week OR Partial Compensation - From _________________ To ______________ at $ _____________________ per week Section 36 Benefits ________________________ OTHER (specify) __________________________________________ 19. Issues in Dispute (Check all that apply): Liability Fraud OTHER - Average Weekly Wage - Disability - Extent - Causal Relationship to Work §14 (2) (explain ) _________________________________ §14 (1) (specify)________________________________________________________________ _______________________________________________________________________ Dispute of Entitlement Due to Insufficient Documentation Filed Other Attorney Fee Issues _____________________________________________________________ 20. Is Impartial Medical Examination Required?: Yes, Impartial Exam Will be needed - No Impartial Exam is needed (OVER) Form 140 - Revised 7/2010 Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 PURSUANT TO 452 C.M.R. 1.10 (2), AS AMENDED, CHECK OFF THE DOCUMENTATION INCLUDED IN ATTACHED CONFERENCE MEMORANDUM: DOCUMENTS TO BE SENT TO IMPARTIAL PHYSICIAN MUST BE SUBMITTED IN DUPLICATE AND ARRANGED IN CHRONOLOGICAL ORDER EMPLOYEE INSURER ATTACHMENTS: Stipulations of Fact. Exhibits to be marked for identification at hearing. Names of witnesses with summary of anticipated testimony. Medical records to be sent to impartial examiner, accompanied by an itemized list of those records. Hypotheticals to be sent to impartial. Disclosure questions for impartial physician (not to exceed 3 in number). Written objections to medical records submitted, starting with the reasons therefore. Name(s) of additional physician(s) for who(m), at the time of hearing, it is anticipated either party will request a deposition. PURSUANT TO 452 C.M.R. 1.10 (2), COMPLETE THE FOLLOWING: MEDICAL ISSUE(S) IN DISPUTE: MEDICAL SPECIALTY OF IMPARTIAL PHYSICIAN NAMES OF THREE IMPARTIAL PHYSICIANS THE PARTIES HAVE AGREED UPON IN ORDER OF PREFERENCE 1. 2. 3. ESTIMATED LENGTH OF HEARING _________________________ SIGNATURES: EMPLOYEE'S COUNSEL _________________________ INSURER'S COUNSEL _________________________ CHECK THIS BOX IF NO AGREEMENT CAN BE REACHED - EMPLOYER'S COUNSEL (if applicable) ______________________________ FOR DEPARTMENT USE ONLY DISPOSITION: ORD _____________________________ FROM ________________________ TO _____________________ ATTORNEY FEE: $__________________ ADDITIONAL TIME ALLOWED TO FILE DOCUMENTS: _______ DAYS American LegalNet, Inc. www.FormsWorkFlow.com
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