Massachusetts > Workers Comp
Motion For Expedited Conference 125 - Massachusetts
| Motion For Expedited Conference Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 125 The Commonwealth of Massachusetts 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 DIA Board # (If Known): MOTION FOR EXPEDITED CONFERENCE EMPLOYEE: EMPLOYER: ___________________________________________________________ ___________________________________________________________ Please Print or Type This form is used to request an expedited conference relating to: Fraudulent Behavior, Illegal Discontinuance of Compensation; Catastrophic Injuries and Denial Pursuant to § 15A. Instructions are on the reverse side. Please type or print. INSURER/SELF INSURER: _________________________________________________ Now comes the employee/claimant relating to (check one): insurer/self-insurer and requests an expedited conference Fraudulent Behavior Illegal Discontinuance of Compensation Catastrophic Injuries Medical Emergencies Controversy under § 15A as to which of two or more insurers is liable State briefly the specific facts and legal grounds asserted in support of motion. Affidavits in support of Motion may be attached to this form. (If necessary use additional space on reverse side or attach second sheet.) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ CERTIFICATE OF SERVICE I, ________________________________, attorney for _____________________________, hereby certify that I have this date served on the _____________________ this motion, together with any documents in support thereof, by mailing copies of same, via first class mail, postage prepaid, to: ________________________________________ ________________________________________ ________________________________________ Attorney's Signature: ______________________________ Attorney's Name: ______________________________ Attorney's Address: ______________________________ Attorney's Tel. No.: ______________________________ Date: ______________________________ ___________________________________________________________________________________________________ **FOR DEPARTMENT USE ONLY** Motion Allowed Motion Denied __________________________________ Administrative Law Judge _________________________ Date Revised 2/2007 American LegalNet, Inc. www.FormsWorkflow.com Form 125 Reproduce as Needed INSTRUCTIONS FOR PREPARATION AND FILING OF MOTION 1. 2. 3. No motion for expedited conference may be filed unless and until the underlying claim is first conciliated. The reverse side of this form must be completed and signed by the legal representative of the moving party. Missing information may result in delay of assignment to a motion session. The original and three (3) copies of the motion and any documents in support thereof must be mailed to: Central Scheduling Unit Department of Industrial Accidents 600 Washington St, 7th Fl. Boston, MA 02111 4. A copy of the motion and supporting documents must be mailed to the legal representative of the other party. (See Certificate of Service on reverse side of the form). Return envelopes with sufficient postage pre-paid, pre-addressed to each interested party, must be submitted with the motion. If the Board elects to hear oral arguments on the motion, it will notify the parties of the date, time and place for hearing the motion. 5. The signature of an attorney to a motion constitutes a certificate by him/her that he/she has read the motion and accompanying documents; that to the best of his/her knowledge, the information and belief there is a reasonable ground to support it; and that it is not interposed for delay. If it is determined that any party has filed or defended a motion for expedited conference without reasonable ground, the whole cost of the proceedings shall be assessed upon that party pursuant to MGL c. 152, § 14(1). ____________________________________________________________________________________________________ Additional Space: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ______________________________________________________________________
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