The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 Info. Line 800-323-3249 ext. 7470 in Mass. Outside Mass. - 617-727-4900 ext. 7470 http://www.mass.gov/dia CONFERENCE MEMORANDUM DIA Board # (If Known): FORM 140 Form 140 - Revised 11/2017 Reproduce as needed. E M P L O Y E E & I N J U R Y 1. Date (mm/dd/yyyy): C A SE INFO R M A T I O N 2. List Multiple DIA Board Numbers If Necessary: 11. Average Weekly Wage: I S S U E S I N D I S P U T E 13. Has Any Compensation Been Paid: Yes No Accepted Liability Pay Without Prejudice 15. Claims for Compensation: Total Incapacity Under 247 From / / To // at $ per week; AND/OR Partial Incapacity Under 247 From / / To // at $ per week 36 Benefits OTHER (specify) 9. Date of Injury (mm/dd/yyyy): 14. If Yes for #13 Please State Period and Type: From / / To // Under at $ ; and From // To // Under 247 at $ THIS CONFERENCE MEMORANDUM COVER SHEET, SIGNED BY COUNSEL SHALL BE FILED WITH THE ADMINISTRATIVE JUDGE AT THE START OF THE CONFERENCE. 6. Name, Address & 12. No. of Dependents: 16. Issues in Dispute (Check all that apply): Liability Average Weekly Wage Disability Extent Causal Relationship to Work Fraud (explain ) 24714 (1) 24714 (2) OTHER (specify) Attorney Fee Issues Page 1 of 2 (OVER) Please Print or Type 10. Nature & Cause of Injury: 8. Name, Address & Email American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Medical documents for the Impartial Physician: Instructions (PDF, has a table of contents with caption, bookmarked, text recognized and paginated) and submitted by Direct Upload two business days prior to the scheduled Conference proceeding. If hypothetical questions are submitted, they must be uploaded as a separate document. Non-medical documents: I also certify that all non- contents with caption, bookmarked, text recognized and paginated) have been directly uploaded two business days prior to the scheduled Conference proceeding. For Department Use Only Disposition Order: From: To From: To Notes: PURSUANT TO 452 C.M.R. 1.10(2), COMPLETE THE FOLLOWING: Medical Issue(s) in Dispute: Medical Specialty of the Impartial Physician: If there is agreement, name of the Impartial Physician: Injured Body Part(s): If an Impartial is not needed, a separate Form 121A must be filed at Conference. I certify the above to be complete and accurate: Print Name: Print Name: American LegalNet, Inc. www.FormsWorkFlow.com
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