Massachusetts > Workers Comp
Insurers Hearing Memorandum 162 - Massachusetts
| Insurers Hearing Memorandum Form. This is a Massachusetts form and can be used in Workers Comp . |
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The Commonwealth of Massachusetts FORM 162 Department of Industrial Accidents 600 Washington Street 7th Floor, Boston, Massachusetts 02111 Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 http://www.mass.gov/dia Page 1 of 2 INSURERS HEARING MEMORANDUM TO BE COMPLETED BY COUNSEL FOR THE INSURER PRIOR TO HEARING DATE: ____________________________ BOARD #: ________________________ EMPLOYEE: ___________________________________________________ EMPLOYER: ___________________________________________________ INSURER: ___________________________________________________ COUNSEL FOR INSURER: _____________________________________ ADDRESS: _____________________________________ _____________________________________ COUNSEL FOR EMPLOYEE: _____________________________________ ADDRESS: _____________________________________ _____________________________________ ISSUES TO BE ADDRESSED AT HEARING (PLEASE CHECK ALL THAT APPLY): Liability, i.e., deny industrial injury Disability and extent thereof Causal relationship Deny entitlement to 36 benefits Deny entitlement to 13 & 30 benefits Proper notice Proper claim Deny serious & willful misconduct Other____________________________________________________________ Request Permission to Depose: Dr. ________________________________________________________ ________________________________________________________ (over) Form 162 - Revised 8/2004 - Reproduce as needed.<<<<<<<<<********>>>>>>>>>>>>> 2 Page 2 of 2 ISSUES TO BE ADDRESSED AT HEARING: a. Stipulations of Fact: _________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ b. Witnesses at Hearing: 1. _________________________________________________ 2. _________________________________________________ 3. _________________________________________________ 4. _________________________________________________ 5. _________________________________________________ c. Exhibits to be Marked at Hearing: 1. _________________________________________________ 2. _________________________________________________ 3. _________________________________________________ 4. _________________________________________________ 5. _________________________________________________ d. Medical Reports [Under 452 CMR 1.11 (6)]: 1. _________________________________________________ 2. _________________________________________________ 3. _________________________________________________ 4. _________________________________________________ 5. _________________________________________________ Medical Reports must be accompanied by the physicians curriculum vitae or stipulation of qualifications. Will an Interpreter be Needed?: Language to be Interpreted (if applicable): YES NO NOTE: The party offering testimony by a witness who requires an interpreter must provide a certified interpreter at the time of hearing.
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