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This is a Massachusetts form that can be used for Workers Comp.
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FORM 123 The Commonwealth of Massachusetts Department of Industrial Accidents Department 123 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 NO. §37 or §37A Claim Please print or type AGREEMENT UNDER SECTION 37 or 37A 1. Employee's Name (Last, First, MI): Please Note For Injuries on or after 12/23/1991, the insurer must file their quarterly request for reimbursement within two (2) years from the date of the final approval of the Form 123. All subsequent quarterly request for reimbursements must be received by the DIA within two (2) years from the date of payment by the insurer. E M P L O Y E E I N S U R E R 2. Home Address (No. & Street, City, State, Zip Code): 3. Employer's Name: 4. Employer's Address (No. & Street, City, State, Zip Code): 5. Insurance Carrier's Name: 7. Name & Address of Person Able to Verify Information: 6. Insurance Company Address: 8. Telephone Number: 10. First Date of Disability (mm/dd/yyyy): 11. If Employee Died, Enter Date of Death: 9. Paid Through (mm/dd/yyyy): 12. Total Amount to be reimbursed under Section 37 or 37A : $___________________ (Check all that apply to this agreement) NEGOTIATED FULL & FINAL 13. Amount of Quarterly Reimbursements (if any): $________________________ 14. Is employee still receiving weekly compensation benefits? TYPE OF WEEKLY COMPENSATION a. b. c. d. e. Total Disability Temporary (§34) Total Disability Permanent (§34A) Partial Disability (§35) Dependent Coverage (§35A) Surviving Dependents Coverage (§31) Yes No If Yes, please fill out the following COMPENSATION AMOUNT $______________________________ $____________ __________________ $______________________________ $______________________________ $______________________________ f. Other (Specify) ______________________ $______________________________ I hereby certify that the information contained herein is a true accounting of all payments made to the above named employee. ________________________________________________________________ ________________________ Signature of Insurer's Authorized Representative Prepared Date (mm/dd/yyyy) _________________________________________________________________________________________ Name & title (Last, First, MI) I hereby agree to and approve the following reimbursement to be made per the provisions of this agreement. _______________________________________ __________________ _____________________________________________ Signature for the Office of Legal Counsel Date (mm/dd/yyyy) Name & title (Last, First, MI) I hereby agree to and authorize the following reimbursement to be made per the provisions of this agreement. _______________________________________ __________________ _____________________________________________ Date (mm/dd/yyyy) Name & title (Last, First, MI) Signature for the Office of the Commissioner Reproduce as needed. Form 123 - Revised 7/2013 American LegalNet, Inc. www.FormsWorkFlow.com
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