Conference Memorandum Cover Sheet {140}

The Commonwealth of Massachusetts Department of Industrial Accidents Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111 - 1750 Info. Line (800) 323 - 3249 Inside Mass. / (857) 321 - 7470 Outside Mass. www.mass.gov/dia CONFERENCE MEMORANDUM DIA Board # (If Known): FORM 140 Form 140 - Revised 7/2019 Reproduce as needed. E M P L O Y E E & I N J U R Y 1. Date (mm/dd/yyyy): C A S E I N F O 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. 12. No. of Dependents: 16. Issues in Dispute (Check all that apply) : Liability Average Weekly Wage Disability Extent Causal Relationship to Work Fraud (explain ) 247 14 (1) 247 14 (2) OTHER (specify) Attorney Fee Issues Page 1 of 2 (OVER) Please Print or Type 10. Nature & Cause of Injury: American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Medical documents for the Impartial Physician: I certify that all medical documents (PDF, bookmarked, and text recognized) to be sent to the Impartial Physician have been uploaded via CMS on or before the date of the scheduled Conference proceeding. If hypothetical questions are submitted, they must be uploaded separately via CMS Non - medical documents: I certify that all non - medical documents (PDF, bookmarked and text recognized) have been uploaded via CMS on or before the date of 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