Notification Of Withdrawal Of Claim Or Complaint {109}

FORM 109 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 The Commonwealth of Massachusetts Department of Industrial Accidents ­ Department 109 DIA Board # (If Known): NOTIFICATION OF WITHDRAWAL OF CLAIM OR COMPLAINT DO NOT USE THIS FORM TO INDICATE CHANGE OF COUNSEL. PLEASE USE FORM 114 FOR THAT PURPOSE. 1. Party Filing this Form is: Insurer Employee Employee's Attorney Third Party (Describe: Physician, Hospital, Medical Vendor, Lien Holder) 2. Employee's Name (Last, First, MI): 3. Employee's Social Security Number*: 4. Employee's Address (No. and Street, City, State, Zip Code): 5. Employee's Telephone Number: 6. Name & Address of Employee's Attorney: 7. Telephone Number of Employee's Attorney: 8. Date of Injury (mm/dd/yyyy): 9. Employer's Name & Address (No. and Street, City, State, Zip Code): 10. Insurer's Name & Address (No. and Street, City, State, Zip Code): 11. Withdrawing From: Claim for Benefits Complaint for Modification or Discontinuance Third Party Claim Claim for Illegal Discontinuance Complaint for Recoupment Other (specify) 12. Preparer's Name & Address (No. and Street, City, State, Zip Code): 13. Preparer's Signature ("On-File" is NOT acceptable, must have signature.): 14. Date Prepared (mm/dd/yyyy): *Disclosure of Social Security Number is Voluntary. It will aid in the processing of documents. Please Print Clearly or Type. Unreadable forms will be returned. Form 109 - Revised 7/2013 - Reproduce as needed. American LegalNet, Inc. www.FormsWorkFlow.com