Conference Memorandum Cover Sheet {140} | Pdf Fpdf Doc Docx | Massachusetts

Conference Memorandum Cover Sheet {140}

Massachusetts/Workers Comp/
Conference Memorandum Cover Sheet {140} | Pdf Fpdf Doc Docx | Massachusetts

Conference Memorandum Cover Sheet Form

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This is a Massachusetts form that can be used for Workers Comp.

Last updated: 7/21/2015

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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. 7470 in Mass. Outside Mass. - 617-727-4900 ext. 7470 http://www.mass.gov/dia DIA Board # (If Known): CONFERENCE MEMORANDUM 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. 1. Date (mm/dd/yyyy): C A S E I N F O R M A T I O N 3. Claimant's Name & Address (No., Street, City, State & Zip Code): 2. List Multiple DIA Board Numbers If Necessary: 4. Name, Address & Email Address of Claimant's Attorney: 5. Insurance Carrier's Name & Address: 6. Name, Address & Email Address of Insurer's Attorney: 7. Employer's Name, Address & Email Address: 8. Name, Address & Email Address of Employer's Attorney: 9. Date of Injury (mm/dd/yyyy): E M P L O Y E E & I N J U R Y 10. Nature & Cause of Injury: 11. Average Weekly Wage: 12. No. of Dependents: 13. Has Any Compensation Been Paid: Yes 14. If Yes for #13 Please State Period and Type: From _____/_____ /_______ From _____/_____/_______ To ______/______/______ Under § __________ at $ _______________; and To _____/______/______ Under § __________ at $ _______________ No Accepted Liability Pay Without Prejudice 15. Claims for Compensation: Total Incapacity Under § _______From ____/____ /_____ AND/OR To ______/______/______ at $ ___________ per week; To ______/______/______ at $ ___________ per week Partial Incapacity Under § _______From ____/____ /_____ § 36 Benefits ________________________ OTHER (specify) __________________________________________ I S S U E S I N D I S P U T E 16. 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)________________________________________________________________ _______________________________________________________________________ Attorney Fee Issues _____________________________________________________________ (OVER) American LegalNet, Inc. www.FormsWorkFlow.com Form 140 Reproduce as needed. Page 2 of 2 Medical documents for the Impartial Physician: I certify that all medical documents to be sent to the Impartial Physician have been submitted in an electronic format or CD form (PDF, bookmarked, and text recognized) on or before the date of the scheduled Conference proceeding. If hypothetical questions are submitted, they must be electronically submitted as a separate document. Non-medical documents: I certify that all non-medical documents have been submitted in electronic format or CD form (PDF, bookmarked and text recognized) on or before the date of the scheduled Conference proceeding. 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: Employee's Attorney Signature: ____________________________________________________________ Print Name: ____________________________________________________________________________ Insurer's Attorney Signature: ______________________________________________________________ Print Name: ____________________________________________________________________________ For Department Use Only Disposition Order: ______________________________________________ From: _________________________________ To ________________________________ From: ________________________________ To ________________________________ Attorney's Fee: _______________________________________________ Notes: _________________________________________________________________________________________ _________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com