Insurers Hearing Memorandum {162} | Pdf Fpdf Docx | Massachusetts

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Insurers Hearing Memorandum {162} | Pdf Fpdf Docx | Massachusetts

Insurers Hearing Memorandum {162}

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

Alternate TextLast updated: 8/22/2019

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HEARING MEMORANDUM DATE: BOARD #: EMPLOYEE: EMPLOYER: INSURER: COUNSEL FOR INSURER: ADDRESS: COUNSEL FOR EMPLOYEE: ADDRESS: ISSUES TO BE ADDRESSED AT HEARING ( PLEASE CHECK ALL THAT APPLY ): Liability, i.e., deny industrial injury Disability and extent thereof Causal relationship Deny entitlement to 247 36 benefits Deny entitlement to 247 13 & 247 30 benefits Proper notice Proper claim Deny serious & willful misconduct Other Request Permission to Depose: Dr. TO BE COMPLETED BY COUNSEL FOR THE INSURER PRIOR TO HEARING Page 1 of 2 Form 162 - Revised 7/2019 - Reproduce as needed. 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 (over) FORM 162 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 a. Stipulations of Fact: b. Witnesses at Hearing: 1. 2. 3. 4. 5. c. Exhibits to be Marked at Hearing: 1. 2. 3. 4. 5. d. Medical Reports [Under 452 CMR 1.11 (6)]: 1. 2. 3. 4. 5. qualifications. ISSUES TO BE ADDRESSED AT HEARING: Will an Interpreter be Needed?: YES NO Language to be Interpreted (if applicable): NOTE: The party offering testimony by a witness who requires an interpreter must provide a certified interpreter at the time of hearing. American LegalNet, Inc. www.FormsWorkFlow.com

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